Decision-making framework

Using the Decision Making Framework (nursing and midwifery) to guide nursing and midwifery scopes of practice

What defines Australian nursing and midwifery practice?

Australian nursing practice is defined through practice standards, codes and guidelines adopted by the Australian Health Practitioners Regulation Agency (AHPRA) and the Nursing and Midwifery Board of Australia (NMBA) at the introduction of national registration under the ‘Health Practitioner Regulation National Law (Victoria) 2009’.  

Nursing practice is further defined through competencies and practice standards for enrolled nurses, registered nurses, and nurse practitioners. The national competency and practice standards are the framework under which all nurses and midwives are licensed and authorised to practice. Practice is further defined through the nursing code of ethics and code of conduct.

Midwifery practice is defined through the midwifery competency standards, code of ethics and code of conduct. The nursing and midwifery decision making frameworks help nurses and midwives make practice decisions that satisfy the practice guidelines, codes and standards. The decision making frameworks can be accessed at the Nursing and Midwifery Board of Australia.

What is ‘scope of practice’?

The decision making framework for nursing and the framework for midwifery define a scope of practice for these specific professions. A profession’s scope of practice incorporates the full spectrum of roles, functions, responsibilities, activities and decision making capacity that individuals within that profession are educated, competent and authorised to perform(1). Moreover, the scope of practice of an individual nurse or midwife may be more specifically defined than the scope of practice of their profession, and is generally more in accordance with their individual registration to practice and in accordance with their educational preparation, authorisation and assessed competence in the specific area/s of practice. The scope of practice of an individual practitioner may therefore be variable depending upon the individual practitioners recency of practice in a practice setting and their underpinning education, knowledge, skill and competence, when juxtaposed with the professional practice standards for nursing and/or midwifery as well as being guided by the key elements of the Decision Making Framework for nursing and/or midwifery, together with specific organisational policy and procedure to support the individuals scope of practice.

Do I need to be credentialed to achieve my scope of practice?

The scope of practice of an individual nurse or midwife is sometimes mistakenly referred to as credentialing. Credentialing has, in international practice contexts, been promoted as a means of assuring quality and protecting the public by confirming that individuals, programs, institutions or products meet agreed standards. In Australia, statutory regulation in the form of registration through the NMBA defines scope of practice and provides this ‘quality assurance’ rather than any additional or specific credentialing process.

Through the National Registration and Accreditation Scheme, outlined under the Health Practitioner Regulation National Law Act 2009 (National Law), the safety and quality of health care is assured for the Australia public. The statutory regulation of registered nurses, registered midwives and enrolled nurses begins with initial registration following successful completion of an accredited education program. Entry to practice programs for nurses and midwives requires graduates to meet minimum standards for practice, as set down by the NMBA.  A nurse practitioner has achieved advanced practice competence at Masters level in a specific area of practice expertise and has been endorsed as a nurse practitioner through the endorsement process and statutory regulation with NMBA. Nurse practitioners are not required to undertake any additional credentialing process.

At the time of initial registration to practice, nurses and midwives are listed on the AHPRA Public Register for health practitioners. Following initial registration, and in order to maintain the credentials to practice, registered and enrolled nurses, nurse practitioners, registered midwives and eligible midwives must undertake an annual renewal process. To renew registration, they must demonstrate adherence with the registration standards, which include recency of practice, continuing professional development hours, professional indemnity insurance and criminal history provisions.

Through this process, the public and employers of nurses and midwives are able to validate the health practitioner’s registration status and view any associated conditions, notations or endorsements by accessing the NMBA Public Register.

Some nursing and midwifery professional organisations promote other types of accreditation/certification/authentication processes that are voluntary and self-regulated, and are sometimes imposed as employment conditions.

Do personal care workers and health assistants in nursing have a scope of practice?

Assistants in nursing, like personal care workers and health assistants in nursing do not have a defined scope of practice as they are not regulated health practitioners like nurses and midwives. Therefore, nurses and midwives should refer to the decision making framework to guide their decisions on whether they need to undertake a nursing or midwifery activity themselves or whether it is possible to delegate an activity.

How does the decision making framework guide practice?

The nursing and midwifery decision-making frameworks were developed to help ensure patient or client safety.

Decisions on whether a nurse or midwife performs an activity themselves or delegates the task to a non-nurse/midwife have to be based on sound risk management principles, along with relevant professional standards, regulatory and legislative frameworks. These are some of the issues to consider:

  • Is the activity within the individual’s scope of practice?
  • Has the patient/consumer/client received a comprehensive health assessment from the responsible registered nurse or midwife prior to the decision being made?
  • Accountability remains with the registered nurse delegator for any activity delegated to the enrolled nurse.
  • Enrolled nurses are accountable for making decisions about their own scope of practice before accepting a delegation.
  • Does the organisation support the practice?
  • Have the quality and risk management framework been considered?
  • Are their sufficient staff and/or access to other relevant staff to support the contemplated practice?
  • Must the activity only be performed by a registered nurse or midwife?
  • Is there any specific jurisdictional legislation that needs to be considered?
  • What is the patient’s health status and what are the benefits of the practice for them?
  • Does the activity meet the professional practice standard or evidence?
  • What is the model of care?
  • What educational preparation has been undertaken to support the activity?
  • Who is the most appropriate person to undertake the activity?
  • Is there professional consensus for the delegation to someone else?

(1) Nursing and Midwifery Board of Australia. 2007. (Rebranded). National Framework for the Development of Decision-Making Tools for Nursing and Midwifery Practice