As patients require increasingly complex care, health care organizations can no longer afford to underleverage the skills of frontline nurses.

This study equips members to adjust the structure and timing of patient care assistant (PCA) shifts to reliably deliver all elements of care; cultivate willingness to delegate by building nurses’ trust in PCA skills and formalizing peer delegation; foster interprofessional understanding of nursing’s role on the care team; and appropriately expand nursing practice to eliminate unnecessary patient care delays.

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Executive Summary

Struggling to define 'top-of-license' practice

There is widespread industry and organizational support for “top-of-license” nursing practice. Yet, many organizations have struggled to achieve—or clearly define—this aim. To equip nurses to practice to the full extent of their training, leaders must first agree on the core responsibilities required to meet the needs of increasingly complex patients.

Based on input from nursing leaders in a variety of care settings, we define top-of-license nursing practice as eight responsibilities.

Two barriers impeding nurse focus on core responsibilities

But defining these responsibilities is only the first step in achieving top-of-license nursing practice; organizations also must address two barriers that prevent nurses from focusing on their core responsibilities:

• Protect nurses from avoidable time sinks. Streamline nursing documentation, improve reliability of support staff , and cultivate nurses’ willingness to appropriately delegate work.
• Remove interprofessional barriers to full scope of nursing practice. Enhance physicians’ and other peer professionals’ understanding of nursing’s role and expand nurse clinical decision making to enable nurses to provide more timely patient care, both within and between care settings.

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Achieving Top-of-License Nursing Practice outlines 20 best practices for ensuring frontline nurses have the time and interprofessional support they need to practice to the full extent of their training and skills.