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Chapter 4 - Nursing

Part 3 - Professional Services

Title Section
Introduction 3-4.1
    Purpose 3-4.1A
    Policy 3-4.1B
    Philosophy of Nursing 3-4.1C
    Goal 3-4.1D
    Objectives 3-4.1E
    Accountability 3-4.1F
    Definitions 3-4.1G
    The National Council of Nursing (NCON) 3-4.1H
    Program Planning and Evaluation 3-4.1I
Management Responsibilities and Operating Relationships 3-4.2
    Division of Nursing 3-4.2A
    Area Offices 3-4.2B
    Service Units 3-4.2C
Nursing Services Administration (Service Unit Level) 3-4.3
    Philosophy of Nursing Service Organization 3-4.3A
    Organization of Nursing Services 3-4.3B
Resource Management 3-4.4
    Personnel Management 3-4.4A
    Fiscal/Budgetary Management 3-4.4B
    Staffing 3-4.4C
    Patient Classification 3-4.4D
    Recruitment and Retention 3-4.4E
    Nursing Management Information Systems 3-4.4F
Nursing Practice Management 3-4.5
    Standards of Practice 3-4.5A
    Standards of Care 3-4.5B
    Nursing Policy & Procedure Manuals 3-4.5C
    IHS Division of Nursing Program Guide 3-4.5D
    Nursing Process 3-4.5E
    Collaborative Practice 3-4.5F
Quality Improvement and Risk Management 3-4.6
    Quality Improvement 3-4.6A
    Risk Management 3-4.6B
    Standards Compliance 3-4.6C
Records and Reports 3-4.7
    Records 3-4.7A
    Reports 3-4.7B
Staff Development Activities 3-4.8
    Definitions 3-4.8A
    Types of Training and Education 3-4.8B
    Continuing Education Approval for Nursing 3-4.8C
    Nursing Education Funds 3-4.8D
Nursing Education Programs 3-4.9
    General 3-4.9A
    IHS Career Ladder Development Programs 3-4.9B
    IHS Nursing Education Center for Indians 3-4.9C
    IHS Long Term Training Programs 3-4.9D
Opportunities for Students 3-4.10
    IHS P.L. 94-437 Extern Programs 3-4.10A
    Commissioned Officer Student Officer Programs 3-4.10B
    Student Affiliations 3-4.10C
Advanced Practice Nurses 3-4.11
    Purpose 3-4.11A
    Background 3-4.11B
    Authorities 3-4.11C
    Policy 3-4.11D
    Responsibilities 3-4.11E
    Scope of Practice 3-4.11F


  1. Purpose.

    This Chapter sets forth the philosophy objectives, scope of activities, staff responsibilities, operational relationships, standards, and general policies relating to nursing within the Indian Health Service (IHS).  The authority, the responsibility, and the accountability for nursing practice remains within nursing.  Nursing activities in the health care setting are dependent, interdependent, and intra-dependent with other disciplines utilizing the team concept for the provision of health care services to clients, families, and communities.

  2. Policy.

    The policy of IHS Nursing is to:

    1. Provide a comprehensive Nursing Program with all components of the discipline of Nursing represented.
    2. Provide, within available resources and priorities, the delivery of high quality comprehensive nursing services in accordance with professionally determined standards of nursing practice in all settings emphasizing the promotion of health, prevention of disease, health maintenance, and restoration of health within the client's functional capacity.
    3. Assure quality by reviewing and evaluating nursing practice in accordance with standards developed by the IHS and other nationally recognized organizations such as the American Nurses Association (ANA), National League for Nursing (NLN), Joint Commission on Accreditation of Healthcare Organizations, etc.
  3. Philosophy of Nursing.

    Nursing is an art and a science based on the knowledge of human understanding, scientific principles and specific nursing knowledge.  Nursing is defined as the diagnosis and treatment of human responses to actual or potential health problems.  The practice of nursing is based on the nursing process; which is the assessment, planning, intervention, and evaluation of nursing care.  Nursing practice occurs in any setting and at any stage in the human life cycle.

    The IHS Division of Nursing recognizes the cultural diversity of all clients, and in particular of the American Indian and Alaska Native (AI/AN) clients served.  IHS nurses plan culturally sensitive care as an integral part of their nursing practice.

    The IHS recognizes the variety of Levels of expertise among providers of nursing services and that each member of the team responsible for practicing nursing in accordance with her/his own level of education, experience, knowledge, skills, and abilities, and as defined in their state nurse practice act, license, and the facility's policies under which they work.  The two levels of nursing education are professional and technical.  All registered nurses are professional nurses.  Preparation at the baccalaureate level is essential to meeting future needs for leadership and clinical expertise.

    The IHS Division of Nursing values the worthwhile contributions of the licensed practical nurse (LPN) and the nursing assistant for the delivery of healthcare to beneficiaries.

  4. Goal.

    The Goal of the IHS is to raise the health status of the AI/AN to the highest possible level.  The goal of the IHS Division of Nursing is to provide high-Quality, client-centered nursing care that is responsive to individual, family and community needs through use of available human and material resources.

  5. Objectives.
    1. Identify issues, clarify positions, and formulate policies which impact on the recipients of nursing services.
    2. Provide quality nursing care with emphasis on the promotion of health, prevention of disease, health maintenance, and restoration of health within the client's functional capacity.
    3. Collaborate with other health care disciplines in the provision of health care.
    4. Collaborate with tribal health groups and actively participate in tribal health programs.
    5. Promote active participation of the consumer in all phases of health care.
    6. Develop staff to improve client care and strengthen nursing services.
    7. Provide continuity and consistency of care through coordination of nursing services and the utilization of referral systems.
    8. Provide optimum nursing care through the effective utilization of nursing personnel recognizing the diverse backgrounds of education, experience and abilities.
    9. Promote the interest of Native Americans in health careers and provide encouragement and guidance to those students pursuing a nursing career.
    10. Conduct Surveys, studies and research to determine the impact of findings on nursing care.
  6. Accountability.

    Nursing within the IHS is accountable:

    1. To the individuals, families, and communities who receive nursing services for providing safe, competent, and quality care.
    2. To itself, to peers and to the nursing profession for setting and maintaining the highest possible standards of care.
    3. To the agency to support and attain its goals.
    4. To the community for improving the health care delivery system and the environment.
  7. Definitions.
    1. Professional Nursing:  Professional nursing is the performance of services requiring substantial knowledge of the biological and behavioral sciences, humanities and nursing sciences.  Professional nursing applies nursing knowledge as the basis of assessment, diagnosis, planning, intervention, and evaluation of nursing care.
    2. Practical Nursing:  Practical nursing is the performance of skilled nursing services under the supervision of a registered nurse.
    3. Ancillary Nursing:  Ancillary nursing is the performance of basic nursing/patient care support services under the supervision of a registered nurse.  Performance of nursing/ medical procedures requiring licensure must not be delegated to ancillary nursing personnel.
    4. Nursing Administration:  The primary focus of nursing administration is to provide leadership and direction for a comprehensive nursing program.  The nurse executive participates in policy and decision making processes at all organizational levels.
    5. Hospital Nursing Service:  The primary focus for hospital nursing is the delivery of comprehensive inpatient nursing care.  This is accomplished through the nursing process, i.e., client assessment, development and implementation of a plan of nursing care coordinated with the overall plan of health care, and the evaluation of the effectiveness of the nursing care.  Strong emphasis is placed on managing continuing care needs after discharge and the teaching of the care givers.
    6. Ambulatory Nursing Service:  The primary focus of ambulatory nursing is to provide comprehensive nursing services and education to the client and family in the ambulatory setting.  This is accomplished by utilizing the nursing process and coordinating with the overall health plan.  Continuity of care is accomplished through coordination of services with inpatient and public health programs and utilization of community resources.
    7. Public Health Nursing Service:  The primary focus of public health nursing is the prevention of illness, promotion and maintenance of health through the provision of therapeutic services, counseling, education and advocacy services.  This is accomplished through assessment and identification of the individual, family and community needs, promotion of consumer participation in establishing health goals, planning programs to meet identified needs and coordination of community health programs and services.  The public health nursing program is flexible and individualized to meet needs within existing resources and takes into account prevailing economic, cultural, social, and geographic characteristics.
    8. Specialty Nursing Practice:  The clinical specialist is a nurse who, through advanced study and supervised practice, is an expert in a specialized area of nursing.

      Nurses who practice in specialty areas may include:

      1. Clinical Nurse Specialist (Graduate level preparation)
      2. Nurse Practitioners
      3. Nurse Midwives
      4. Nurse Anesthetists
      5. Nurse Educators
      6. Infection Control
      7. Quality Assurance/Improvement Nurses
  8. National Council of Nursing.   Replaced with Circular 23-06, National Nurse leadership Council – Charter, dated Aug. 3, 2023
  9. Program Planning and Evaluation.
    1. General.

      This process provides the guidelines and methods for identifying health problems, defining objectives, developing plans of action, identifying program deficiencies, measuring progress, and establishing a basis for the justification of funds.  The service unit/tribal specific health plan reflects all program plans and joint planning by tribal representatives and the various health disciplines within the service unit responsible for developing, implementing and evaluating the program.

    2. Nursing Role in Planning at Headquarters, Area and Service Unit Levels.

      The IHS Program Plan is a compilation of Area and service unit plans.  Nursing shall participate in reviewing, recommending and implementing changes at Headquarters, Area, and service unit levels.

    3. Evaluation.

      Nursing shall participate in the on-going evaluation of nursing programs at all levels of the agency.


  1. Division of Nursing.

    The Director, Division of Nursing (Chief Nurse), has the authority and responsibility for the IHS nursing program.  The major functions of this office are:

    1. Administration.
      1. Plans, organizes, sets standards, coordinates, analyzes and evaluates all nursing programs to establish a quality program meeting the needs of the AI/AN.
      2. Provides consultation, guidance, direction and technical assistance to the Director, IHS; IHS Headquarters staff; Directors, Area offices and key staff; Area nursing consultants and tribal health administrators and staff.
      3. Prepares division budget and identifies resources essential for program implementation.
      4. Participates in decision-making process for Agency program planning, implementation and evaluation.
      5. Develops and recommends nursing policies to the Director for adoption.
      6. Participates in the development and recommendation of Agency policies that affect health care.
      7. Communicates with Area nursing program consultants regarding current concepts and trends in Nursing and health related issues.
      8. Administers the Nurse Education Center for Indians (NECI) Program.
    2. Program Planning and Evaluation.
      1. Assesses data from a variety of sources to establish, develop and evaluate new Nursing programs.
      2. Conducts periodic Area nursing program reviews and monitors progress towards achieving recommendations.
    3. Research and Publications.
      1. Identifies the need for and promotes nursing research in the IHS.
      2. Provides technical assistance to Area nursing program consultants in planning nursing research activities.
      3. Advises the IHS Office of Health Programs Research and Development (OHPRD) on nursing research.
      4. Disseminates knowledge gained from research to improve nursing practice.
    4. Recruitment and Retention.
      1. Develops the annual national nurse recruitment and retention plan.
      2. Establishes, conducts, monitors and evaluates the national IHS nursing recruitment program.
      3. Plans, implements, manages and evaluates the national nurse recruiter program.
      4. Develops and maintains incentive programs for the recruitment and retention of nursing students and staff.
      5. Provides nurse recruitment and retention consultation and support to Area nursing program consultants and Area recruitment and retention staffs.
    5. Budget.
      1. Plans, administers and evaluates the Division of Nursing budget.
      2. Analyzes data and makes recommendations to support nursing program needs.
    6. Liaison.
      1. Represents the Division of Nursing by participating in establishing and maintaining liaison with professional, national and civic organizations and tribal groups.
      2. Represents IHS nursing in federal nursing personnel issues including development of qualifications, appointments, classification standards, personnel policies, and career guidelines.
    7. Human Resource Management.
      1. Negotiates and advocates for the funding of nursing education programs.
      2. Collaborates with Area nursing program consultants in planning career development for nursing personnel.
      3. Negotiates and advocates for the funding of academic programs for nursing.
    8. Project Officer.
      1. Serves as the project officer for contracts and grants on an ad hoc basis.
      2. Provides technical assistance for contracts and grants on an ad hoc basis.
    9. Public Policy and Legislative Formulation.

      Represents the division at congressional hearings and other key governmental activities as the expert in IHS Nursing.

  2. Area Office.

    The Area nurse program consultants have the authority and responsibility for the Area nursing services program.  Their functions include:

    1. Administration.
      1. Endorses and supports the IHS Division of Nursing philosophy.
      2. Establishes Area nursing program policy.
      3. Promotes the establishment of nursing administrative policies and procedures at the service units/tribal programs which enhance the practice of Nursing.
      4. Develops specific Area nursing goals and standards which are compatible with the IHS goals and objectives.
      5. Participates in the establishment of Area health care policy.
      6. Participates in the development and establishment of position standards and scope of work for nursing.
      7. Develops and maintains a system of nursing records and reports.
      8. Collaborates with other professional and advisory health groups in planning for comprehensive services.
      9. Participates in planning the development of new and remodeling of existing facilities.
      10. Participates in the development, negotiation, monitoring and evaluation of contracts for nursing services.
      11. Serves as an expert to the Area Director and staff on all matters related to nursing.
      12. Participation in the Area Emergency Medical Systems program in a nurse consultant role.
    2. Program Planning and Evaluation.
      1. Conducts service unit nursing program reviews for adherence to Agency, Area and service unit policies, and accrediting body standards.
      2. Assesses and reviews the nursing quality assurance programs in the Service Units.
      3. Prepares an annual Area nursing program plan.
      4. Participates as a peer reviewer in the Division of Nursing Area nursing program review processes.
    3. Research and Publications.
      1. Initiates and participates in nursing research activities.
      2. Reviews research and publication proposals through participation in an Area committee or on an ad hoc basis as requested.
      3. Assists service units in identifying the need for and the planning for nursing research activities.
      4. Disseminates knowledge gained from research findings to improve nursing practice in the Area.
    4. Recruitment and Retention.
      1. Monitors the Area recruitment plan based on the IHS national nursing recruitment program.
      2. Provides consultation for selection and placement of nursing personnel.
      3. Assists in the placement of scholarship recipients.
      4. Monitors factors influencing retention and job satisfaction.
    5. Budget.
      1. Provides data and participates in determining budgetary requirements necessary to carry out the nursing program.
      2. Plans and administers the Area nursing budget.
    6. Liaison.

      Represents nursing by establishing and maintaining liaison with community, tribal, state, national agencies and professional organizations.

    7. Human Resource Management.
      1. Participate in orientation and inservice programs for nursing personnel within the Area.
      2. Participate in planning and implementation of nursing continuing education programs.
      3. Collaborative with service unit nurse executives in planning career development for nursing personnel.
      4. Collaborates in the development of agreements with educational institutions for the use of IHS clinical facilities.
      5. Coordinates, monitors and assists the NECI students.
    8. Contracting Process.
      1. Assists tribal groups and others in the initiation of the contract process for nursing services by providing scopes of work, position descriptions, qualification standards, and other technical assistance when required.
      2. Provides consultation and assistance to tribal groups and others for monitoring and maintaining contract nursing services in Area.
    9. Project Officer.
      1. Serves as representative to tribal groups providing technical assistance in the operation of nursing programs.
      2. May serve as a project officer as assigned.
      3. Conducts site visit reviews to monitor progress for conditions stated in the contract.
  3. Service Units.

    The nurse executives have the authority and responsibility for their respective service unit nursing service programs.  The functions are:

    1. Administration.
      1. Develops written philosophy and objectives for the nursing program that are compatible with those of the IHS Division of Nursing, the Area, and the service unit.
      2. Establishes and implements nursing program standards.
      3. Establishes and implements nursing program policies and procedures.
      4. Plans and implements a quality assurance/improvement program.
      5. Fulfills the requirements established by the accrediting body for nursing service.
      6. Manages personnel actions.
      7. Validates competence of nursing personnel.
      8. Determines a staffing plan which will accomplish the stated objectives and standards of the nursing program.
      9. Organizes the nursing program to deliver nursing care.
      10. Develops and maintains an effective recording and reporting system.
      11. Executes the delegated authority for the fiscal management of the service unit nursing program.
      12. Participates with leaders from the governing body, management, medical staff, and clinical areas in the facility's decision-making structures and processes.
    2. Program Planning and Evaluation.
      1. Conducts an on-going evaluation of the nursing program.
      2. Coordinates service unit nursing programs with tribal health programs.
      3. Plans with the service unit staff for new facilities and effective utilization of existing ones.
      4. Participates in service unit program planning, implementation and evaluation.
    3. Research & Publications.
      1. Initiates and conducts studies to improve client care and effective utilization of nursing personnel.
      2. Shares new knowledge from research and incorporates these findings into nursing practice.
      3. Submits research and publication proposals to Area for Agency review and approval.
    4. Recruitment and Retention.
      1. Participates in service unit recruitment and retention processes, and develops strategies to address identified needs.
      2. Monitors and evaluates factors influencing recruitment and retention, ie. career planning, exit interviews, etc.
      3. Communicates with Area consultant and nurse recruiter to identify staffing needs and submits monthly reports.
    5. Budget.
      1. Plans and administers the nursing program budget.
      2. Collects, analyzes and presents data to justify nursing program needs.
    6. Liaison.
      1. Approves and implements agreements with educational agencies for the use of the IHS clinical facilities.
      2. Represents nursing to community, professional and civic organizations, and tribal groups.
    7. Human Resource Management.
      1. Provides on-going staff development programs including orientation, inservice and continuing education.
      2. Collects data for, and counsels individual nurses for individual career plans.
    8. Contracting Process.

      Participates in the process for contract nursing services as appropriate.

    9. Project Officer.
      1. Provides consultation and technical assistance to tribal groups and others in the administration and management of health programs.
      2. Prepares reports as required to evaluate project(s).

  1. Philosophy of Nursing Service Organization.

    The IHS Division of Nursing believes that the increasing complexities of nursing and the increased acuity in all service environments mandates leadership of nursing services by a competent, qualified registered nurse.  These qualifications should be based upon formal education related to management theories and principles, budget principles, research and recent experience of successful attainments of objectives by working through others.

  2. Organization of Nursing Services.
    1. The service unit organizational design should be based on the distinctive focus or purpose of nursing in the clinical setting, the characteristics of the nursing personnel, the needs of the community in which the nursing services are delivered, and the management strategies that are employed.  The nursing administrative design may be modeled on an organizational theory or an existing conceptual model of nursing practice.
    2. Nursing service organization should be designed to be compatible with the service unit's philosophy while facilitating the model of nursing practiced.
    3. The nurse executive/designee shall be a member of the organizational planning, advisory, and decision-making structures and processes of the health care facility.  The nurse executive shall report directly to the facility executive/director.
    4. The nursing service's organizational effectiveness shall be measured by tools approved by the IHS Division of Nursing.
    5. The nursing department's services shall be appropriately integrated with the medical staff and other clinical, medical administrative and support services that provide and contribute to patient care.
    6. The IHS Division of Nursing recognizes that there are three distinct practice areas for professional nurses.  These areas of nursing practice are:
      1. Hospital Nursing.

        Nursing services are provided to the client and family in an acute care, inpatient setting.  A professional registered nurse is responsible for the total care of the hospitalized client at all times and is accountable to the client, the institution, nursing peers and the prevailing standards of practice.

      2. Ambulatory Nursing.

        Ambulatory nursing services encompasses outpatient and emergency services provided to the client and family in an ambulatory care setting that may be located in a free standing clinic, hospital outpatient department, health center or station.  A professional registered nurse shall be responsible for the administration, delivery and evaluation of the ambulatory nursing care and services.  A professional nurse shall be in the unit during all regularly scheduled hours of operation.

      3. Public Health Nursing.

        Public health nursing services are provided to the individual, family and community in the community setting which may be the home, clinic, school, trading post or community building.  A professional registered nurse shall be responsible for the administration, delivery and evaluation of public health nursing care and services.  Services are evaluated as they relate to their contribution to the health care of the entire community.

  1. Personnel Management.
    1. Indian Preference.

      Congressional legislation has required an appointment policy that mandates preference in appointments be given to qualified Indians and Alaska Natives.  Implementation of the policy is the responsibility of the Area personnel officer.

    2. Employment Options.
      1. There are two federal employment options available within the IHS:  (1) Civil Service, and (2) The Commissioned Corps of the United States (U.S.) Public Health Service.
      2. Federally employed nurses may be detailed to tribal and urban programs. When this occurs, nurses shall adhere to the local personnel regulations in addition to the federal personnel regulations and shall have both a federal and a tribal/urban supervisor.
      3. Nurses may be employed by tribal and urban programs.
      4. Nurses may also be hired through a variety of private/commercial contracts.
    3. Licensure & Credentialing.
      1. Current licensure as a professional registered nurse (RN) or a licensed practical nurse (LPN/LVN) in a state, the District of Columbia, Puerto Rico, or a territory of the U.S. is required for the initial and continuing employment.
      2. It is the responsibility of the individual nurse to meet the criteria for license renewal.
      3. It is illegal for any person to practice or offer to practice, use any title, abbreviation, sign or device to indicate that he or she is a licensed nurse unless he or she is duly licensed and registered.
      4. The nurse executive must maintain a system for verifying and monitoring nurse licensure.  The nurse executive is responsible to take immediate, appropriate actions for nurses without valid licenses.  These actions will be consistent with personnel policies.
      5. The nurse executive is responsible for identifying the competency and credentialing requirements for nursing practice.  The evaluation of the competency level of individual practitioners to fulfill their assigned responsibilities is documented and updated on an annual basis.
    4. Orientation.
      1. The orientation of the Area nursing program consultant shall be the joint responsibility of the Area director and the IHS Division of Nursing.
      2. The orientation of the service unit nursing service executives (DON/DACN/DPHN) is the joint responsibility of the service unit Director, tribal representatives, and the Area nursing program.
      3. The service unit orientation is the responsibility if the nurse executive or his/her designee.  The orientation should be of sufficient duration and scope based on the individual's training and experience.  Orientation to the community and its culture(s) is an important component.
    5. Position Descriptions and Billets.

      A current and accurate position description or billet shall be provided to the nurse upon employment and readily accessible to nursing supervisors, nurse consultants and accreditation body surveyors.

    6. Standards of Performance.

      The nurse executive shall be responsible for the development, implementation and periodic review of standards of performance for all nursing personnel.

    7. Uniforms.
      1. Commissioned Corps nurses are required to wear the prescribed Commissioned Corps uniform a minimum of one day per week and shall wear it whenever representing the Agency at a meeting or conference.  Facilities may require the Commissioned Corps uniform on a more frequent basis.  When the Commissioned Corps uniform is not worn, the uniform worn shall be the same as required for other nurses in the facility.
      2. Civil service nurses shall follow the uniform guidelines in the IHS Division of Nursing Program Guide.  When uniforms are required, a uniform allowance is granted.
      3. Tribal or urban nurses are expected to follow the uniform policy of their own facility program.
      4. Contracted nurses shall follow the uniform guidelines found in the IHS Division of Nursing Program Guide.
    8. Exit Interview.

      Written exit interviews shall be secured whenever a federally employed nurse resigns or is transferred to another facility.  Refer to the form and directions in the IHS Division of Nursing Program Guide.  Tribal and urban programs are encouraged to solicit similar information whenever nurses resign.

      This information shall be used to assist with recruitment and retention efforts.

    9. Awards and Recognition.

      The IHS Division of Nursing believes that awards and recognition are an integral part of human resource management and strongly encourage the acknowledgment and reward of deserving nursing personnel.  Refer to the IHS Division of Nursing Program Guide for additional information.

    10. Impaired Nursing Practice.

      Impaired Practice as defined by the American Nurses Association Task Force on Addictions and Psychological Dysfunctions, is a professional's inability to meet the requirements of the professional code of ethics and standards of practice because of excessive alcohol or drug use, addiction, or psychiatric illness.

      Professional ethics demand that whenever patient safety is at risk, supervisors and individual nurses are obligated to take appropriate action as defined in the IHS, Civil Service, Division of Commissioned Personnel, or tribal rules and regulations.

      Substance abuse is considered to be a medical condition amenable to treatment.  Treatment should be considered as an alternative to disciplinary action as part of the intervention and management process.

      Diversion of drugs for personal use is illegal and is considered a violation of the Department of Health and Human Services (HHS) standards of conduct requiring supervisory intervention.


      1. Employee Assistance Program - HHS.
      2. Commissioned Corps Personnel Manual, Chapter CC 29, Subchapter CC 29.8, Personnel Instruction 8.
    11. Equal Employment Opportunity (EEO).

      Nursing leadership and staff must adhere to all of the applicable EEO policies, standards and procedures.

  2. Fiscal/Budgetary Management.

    The nurse executive and nursing leaders shall collaborate with other members of the executive team in the budget and resource allocation process to support the achievement of program goals.  This process involves identifying needs through interpretation of appropriate data including management information systems, quality improvement monitoring, community and national trends, projecting cost, setting priorities, distributing resources, monitoring expenditures, and evaluating program outcomes.  Directives and procedures of the respective Financial Resource Program provides overall guidelines for developing, negotiating, monitoring and managing the budget.

  3. Staffing.

    Staffing is the process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patient's demand for care.  There shall be a system for staffing established and implemented in each nursing practice area.  The IHS resource requirement methodology and other IHS approved tools shall be utilized in determining staffing requirements.

  4. Patient Classification.
    1. Patient classification is a tool which assesses individual patient nursing care requirements, quantifies the collective needs based on the assessments, factors in the indirect patient care variables and identifies the required nursing resources.
    2. Patient classification may be used to measure productivity and to assist with long range budget and program planning.
    3. There shall be an IHS approved patient classification and staffing system in place for each nursing practice setting.
  5. Recruitment and Retention.

    The recruitment and retention of qualified nursing personnel is a basic requirement to facilitate the IHS mission of improving and maintaining the health status of the AI/AN people at the highest possible level.

    1. Nurse recruiters are placed in Area offices to facilitate the recruitment, retention and placement of appropriately qualified professional nurses.
    2. The IHS Division of Nursing sponsored nursing recruitment and retention program includes IHS Headquarters nurse recruiter and select Area nurse recruiters.  Some Areas sponsor their own nurse recruiters.  All Area nurse consultants and nurse executives assist with the recruitment and retention activities.
    3. The IHS Division of Nursing and Area professional nurse recruitment and retention plans shall be instituted with periodic reviews, updates, and revisions.
    4. Retention of nurses should be recognized as the responsibility of all people involved in health care delivery systems.
  6. Nursing Management Information Systems.
    1. Philosophy:

      The IHS Division of Nursing supports and promotes the concept that nursing information systems will increase the availability of RNs to clients, improve management decisions through immediate accessibility of pertinent data, and promote the retention of professional nurses by decreasing duplicate and non-nursing documentation.

      Nurses should have access to computer systems and systems support services.  They should participate in developing, evaluating, selecting, and integrating information management systems that support patient care and the efficient utilization of nursing care resources.

      Orientation and training is imperative for appropriate utilization of management information systems and must be accessible to all nurse users.

    2. Nursing Professional Specialty Group (PSG):

      The Nursing PSG participates in the planning, development, and application of nursing management information systems.  Membership of the PSG is comprised of field and Area nurse consultant delegates representing all three nursing practice areas.


Nursing practice management is a complex system based on a theoretical framework that provides support and direction, sets standards, identifies structure and processes in all practice settings and establishes processes for the evaluation, revision and updating of standards, policies and procedures.

  1. Standards of Practice.

    Standards of practice shall be established and implemented which define expectations of professional nursing in interactions with the client, family or a community.

  2. Standards of Care.

    Standards of care shall be established and implemented that define the care a client, family, or a community should reasonably expect as the result of professional nursing interventions.

  3. Nursing Policy & Procedure Manuals.

    Manuals shall be developed and maintained for each nursing program, and be readily available for access and use by staff.  All staff should be able to identify those components that impact on their practice.  The manuals shall be organized to easily facilitate the retrieval and use of information.  The contents shall reflect local practice, the IHS and Area policies, for which the nurse executive is held accountable by the IHS Division of Nursing, Area nursing program and accrediting bodies.  There shall be an organized, documented process for periodic review of the contents of all nursing manuals.

  4. Division of Nursing Program Guide.

    The IHS Division of Nursing Program Guide ("The Blue Book") shall be utilized as a reference for all nursing program activities.  The Blue Book is a compendium of documents related to professional purpose, standards, criteria, values, methods of practice and rationale for program operations.  These documents are intended to facilitate understanding of the IHS nursing programs and to promote interdisciplinary cooperation.  Procedures, guidelines and instructions have been placed in The Blue Book with this revision of the Indian Health Manual, Part 3, Chapter 4, entitled "Nursing."

  5. Nursing Process.

    The nursing process (assessment, diagnosis, planning, intervention, evaluation), the framework of nursing practice, shall be applied and documented in all three areas of nursing practice:  inpatient, ambulatory and public health nursing.

  6. Collaborative Practice.

    Nursing shall support the cooperation of nurses and medical staff to synchronize medical and nursing efforts aimed at achieving optimal patient outcomes.


It is inherent to professional nursing to be concerned that the clients, families and communities receive care that is safe, therapeutic, and consistent with professional nursing standards.  Every member of the nursing program is expected to take a leadership role and an active part in quality improvement and risk management activities.  Principles of total quality improvement are incorporated into all facets of nursing practice.

  1. Quality Improvement.

    Quality Improvement Programs should include the following:

    1. Monitoring and evaluation which assists programs to effectively use their quality assessment and improvement resources by focusing on high-priority quality-of-care issues.  The process includes identification of important aspects of care, use of indicators to monitor these aspects, evaluation of the outcome of patient care, taking actions to improve care or solve problems, evaluation of the effectiveness of those actions and communicating findings.
    2. Utilization review to examine and evaluate the appropriateness of the utilization of health care resources.
    3. Peer review to routinely assess the quality of care provided by members of the same discipline and practice area.
    4. Patient satisfaction to include consumer surveys.
    5. Infection control to conduct surveillance and prevent and control infection.
    6. Safety management which includes general safety, safety education, emergency preparedness, hazardous materials and wastes and safety devices and operational practices.
    7. Quality control addressing the safety and accuracy of biomedical equipment.
    8. Unusual occurrences which examine deviations from the norm such as accidents or treatment errors.
  2. Risk Management.

    Risk management is a quality control program with emphasis on the evaluation of high risk activity or exposure occurring within the health care setting.  It is a multidisciplinary process in which nursing actively participates.  The process includes the early identification, correction, and prevention of risk factors related to the delivery of health care that have the potential to harm consumers and employees.

  3. Standards Compliance.

    Nursing programs shall achieve accreditation and maintain compliance with nationally recognized and the IHS standards of quality.


Records document and communicate nursing clinical activities.  Reports communicate nursing program activities to other levels of the IHS.  These shall be submitted in accordance with Division of Nursing Program Guide instructions.

  1. Records.

    Nursing shall document client interactions and interventions utilizing multidisciplinary forms such as:

    1. Progress Notes (SF-509)
    2. Problem List (IHS-126)
    3. Patient Care Component forms (PCC forms in the IHS-300 & 400 series)
    4. Emergency Visit Record (IHS-114)
  2. Reports.
    1. Service Unit to Area Nursing.
      1. Funded Position Reports - monthly status report of funded, filled, and vacant nursing program positions.
      2. Narrative Report - monthly highlights of activities and program accomplishments, quality improvement activities, problems and future plans.
      3. Periodic Licensure Reports - as requested by the state board of nursing and/or Area Nursing Programs.
      4. Annual Report - sent by the first quarter of the following fiscal year containing factors influencing program, achievements towards meeting program objectives, health problems of major concern, achievements, collaboration with tribal programs, and future goals for the following fiscal year.  Statistical data should be included as specified in the Division of Nursing Program Guide.
      5. Community Health Activity Reports (CHA) and/or Patient Care Component encounter forms are used to generate public health nursing productivity reports.
      6. Patient Classification Reports - compilation of daily patient classification reports submitted monthly or quarterly as specified by program.
      7. Training and Experience Records - submitted as required by the Area nursing program.
    2. Area to Division of Nursing.
      1. Funded Position Reports - a consolidated report sent monthly to the IHS Division of Nursing.
      2. Monthly Narrative Report - an Area nursing program report with highlights from the service units.
      3. Periodic Budget Reports - a report submitted on request.
      4. Annual Report - a compilation of Area and service unit activities for the fiscal year.


Staff development is a vital part of good program management.  It contributes directly to the organizational effectiveness and efficiency by developing skills unavailable through existing recruitment sources, improving employee performance and providing them with the knowledge, skills, and abilities to accommodate changes in technology and program direction.  It also provides for future manpower requirements and upward mobility.

  1. Definitions.

    Staff Development is the process by which the Agency provides the array of activities including, but not limited to, training, inservice, competency development, and continuing education, to enhance the performance of individuals to accomplish its mission and goals.

    Training is the process of providing for and making available to an employee, and placing or enrolling the employee in a planned, prepared, and coordinated program, course, curriculum, subject, system or routine of instruction or education in scientific professional, technical, fiscal, administrative, or other fields which are or will be directly related to the performance of official duties.

    Education is the process of enhancing or changing an individual's knowledge, skills, abilities or attitudes.

  2. Types of Training and Education.
    1. Full-time training.

      Full-time training is training that is the only assignment of an employee during one or more work days or corresponding days of leave granted for purposes of training.

    2. Continuing Education (CE).

      Continuing education is a planned, organized learning experience designed to promote the development of knowledge, skills, and abilities for the enhancement of practice, education, administration and research.

    3. Inservice Education.

      Inservice education is a planned educational program provided in the work setting which is designed to increase competence in specific areas of practice.

    4. Orientation.

      Orientation is the process by which staff members are introduced to the IHS philosophy, goals, policies, procedures, role expectations, and physical, facilities in the work setting.  It is also provided for temporary employees and volunteers.  Orientation is not considered continuing education.

    5. Long-Term Training.

      Long-term training is full-time training of more than 120 consecutive work days for which the government may fund the participant's salary and/or training costs.

    6. Short-term Training.

      Short-term training is full-time training provided for less than 120 consecutive work days.

    7. Part-time Training.

      Part-time training is training which also require the employee to engage in scheduled work during the work week.  This work must be consistent with the employee's job description.  During school breaks, the employee is required to work full-time or take official leave.

  3. Continuing Education Approval for Nursing.

    Sponsors of continuing education have the responsibility to seek approval for their offerings or programs.  The IHS Clinical Support Center has been approved as a provider for nursing continuing education activities by the American Nurses Association Credentialing Center.  The IHS CE approval program offers the advantage of reciprocity in 50 states.  For additional information contact:

    Nursing Continuing Education Approval
    Program Coordinator Indian Health Service
    Clinical Support Center
    1616 East Indian School Road
    Phoenix, Arizona 85016
    Phone: (602) 640-2240
    FAX: (602) 640-2138
  4. Nursing Education Funds.
    1. Sources.
      1. Service Unit Training Monies - The IHS service units may fund short-term training for all categories of employees.  The nurse executive should have input into the decision process for nursing use of funds.
      2. Agency (IHS) Nursing Education Funds - these funds are a congressional budget allocation to the IHS Division of Nursing.  Distribution of these funds is made by the Director, Division of Nursing and the Area nurse program consultants.
    2. Utilization of Funds.
      1. Conducting Area and IHS-wide institutes and workshops.
      2. Attending educational meetings and workshops conducted by other organizations and Agencies, both government and non-government.
      3. Purchasing nursing educational material, equipment and supplies.
    3. Report of Fund Utilization

      Copies of commitment register(s) will be submitted to the IHS Division of Nursing on a quarterly basis.  At the end of each fiscal year, each Area will submit a summary report.

  1. General.

    Program applicants should have a fully satisfactory or commendable performance record, demonstrated scholastic achievement ability, and potential for future contributions.  Specific announcements are published and distributed to the field for consideration.  The IHS Division of Nursing and the Area nursing program or the facility program will evaluate applicants and make selections.

    At times, other in-service training opportunities are offered by other agencies within the U.S. Public Health Service, e.g., National Health Service Corps Scholarships.  In addition, the IHS offers an executive level development program.

    Pay-back obligations are computed at the rate specified by the program operational guidelines or policies.  Service for pay-back obligation is not concurrent with the IHS Loan Repayment Program.

  2. IHS Career Ladder Development Programs.
    1. Operating Room Nurse Residency Training Program.

      This program is open to all applicants and is conducted at the Phoenix Indian Medical Center, Phoenix, Arizona.  For specific details, contact the Area nurse consultants, nurse recruiter or course director.

    2. Critical Care Nurse Residency Program.

      This program is open to all applicants and is conducted at the Alaska Native Indian Medical Center, Anchorage, Alaska.  For specific details, contact the Alaska Area Division of Nursing.

    3. Obstetrical Nurse Residency Program.

      This program is open to all applicants and is conducted in basic and advanced levels in the Oklahoma City Area.  For specific details, contact the Oklahoma Area Division of Nursing.

    4. Public Health Nurse Intern Program.

      This is the oldest (1962) continuous nurse residency program operated by the IHS Division of Nursing.  It provides for the development of public health nurses prepared to meet the needs of independent duty stations within the IHS.  Options exist for this training in many areas.  For further information, contact the Area nurse consultant or recruiter.

      Applicants must have a baccalaureate in Nursing and one year of qualifying patient care experience.  Applicants accept the assignment with the understanding that they will apply for and accept assignment upon completion of the program (12 months) in an IHS high need location.  Applications, Commissioned Corps and Civil Service, are directed to the appropriate Area Nursing Branch.

    5. IHS Hospital Nurse Intern Programs.

      Limited opportunities are available for the new professional (with less than 6 month of experience) to participate in a hospital nurse internship, depending on the availability of funds.  For details, contact the IHS Division of Nursing.

    6. Certified Registered Nurse Anesthetist Program.

      This program is limited to Commissioned Corps Nurse Officers because the funding is from a source outside the IHS Division of Nursing.  This is a long term training program leading to a masters degree in nursing.  The IHS Division of Nursing publishes and distributes announcements, and convenes a review committee to evaluate and select applicants.

    7. Nurses in Management Program.

      This 4-6 week program, developed in 1988, is open to all IHS and tribal nurses seeking development at the nurse manager and nurse executive level.  The course director distributes the course announcements with the specifics of the application process.  All applicants must be endorsed by the IHS Area nursing program.

  3. IHS Nursing Education Center for Indians.

    There are other career ladder opportunities for IHS Native American/Alaska Native Civil Service nurse employees to achieve associate, baccalaureate and masters degrees in Nursing from programs accredited by the NLN.  Vacancy announcements are issued by the Headquarters Personnel Office and selections are made by the Division of Nursing.  A service obligation will be incurred as a result of participation into this program.  Contact the Area Nurse Consultant, Nurse Recruiter or the Division of Nursing for additional information.

  4. IHS Long Term Training Program.

    Limited resources are allocated on a variable basis to the IHS Division of Nursing for the nursing education at the graduate level for civil service and Commissioned Corps nurses.  Headquarters training Office publishes and distributes announcements of educational opportunities.  Selections are made by the Division of Nursing.  A service obligation will be incurred as a result of participation into this program.  Contact the Area Nurse Consultant, Nurse Recruiter or the Division of Nursing for additional information.


Through the student experience program, student nurses are introduced to various Native American/Alaska Native cultures and to the complex economic, social and health problems of the Indian population.  In addition to the broad nursing experience, the students are exposed to the scope of career opportunities in the IHS.

  1. IHS Public Law 94-437 Extern Program.

    This program is authorized under Title I, Section 105 of that legislation.  Scholarship students (Section 104 funding) who are not graduating are entitled to apply for an IHS extern assignment during summer vacation.  The purpose is to gain practical clinical nursing experience while applying information learned in school.  A student nurse extern will be assigned to an IHS facility to participate in a range of nursing activities commensurate with his/her educational preparation and clinical expertise.  For additional information, contact the Area scholarship coordinator.

  2. Commissioned Officer Student Training and Education Program (COSTEP).
    1. The junior COSTEP program is a short term combined work and educational experience designed to acquaint health professions students with opportunities in the US Public Health Service.
    2. The senior COSTEP program is a scholarship type program which enables the student to attend the last year of nursing school with full salary, tuition, and benefits in return for a service obligation.

      For additional information, contact the Area nurse recruiter or Area nurse consultant.

  3. Student Affiliation.
    1. Schools of Nursing.

      Educational agreements between schools of nursing and IHS facilities for clinical practice are encouraged.  The terms of the affiliation shall be set forth in a written memorandum of agreement.

    2. Student Independent Study and Preceptorships.

      The Student Independent Study will be organized within the guidelines established for student affiliation programs, except that supervision is provided by IHS staff instead of school faculty.  Volunteer agreements are required and nurse executives are responsible for validation of credentials, orientation, and performance evaluations.


  1. Purpose.  The purpose of this section is to establish the Indian Health Service (IHS) policy for national scopes of practice for advanced practice nurses (APN).  The APN national scopes of practice is based on Federal supremacy and preempts State law.  The requirements standardize scopes of practice, simplify the credentialing and privileging process, and reduce the complexity of monitoring multiple State licenses at a single site.
  2. Background.  Advanced practice nurses are nurses who hold advanced degrees, have completed an accredited APN program, have received a national certificate in a specialty by the American Nurses Credentialing Center, or other nationally recognized credentialing body, have completed advanced pharmacology education allowing prescribing and dispensing privileges, and are licensed as a registered nurse or APN in at least one United States jurisdiction.
  3. Authorities.
    1. Snyder Act, 25 United States Code (U.S.C.) 13
    2. Transfer Act, 43 U.S.C. 2001
    3. Persons Entitled to Issue Prescriptions, 21 Code of Federal Regulations (CFR), Section 1306.03
  4. Policy.  It is the policy of the IHS that except for controlled substances, the Agency will exercise its authority and the power of Federal preemption to define inpatient and outpatient scopes of practice for APN working for the IHS.  In accordance with 21 CFR Section 1306.03, ?Persons Entitled to Issue Prescriptions,? the health care practitioner?s State of licensure/registration must authorize prescription of controlled substance.  Each IHS facility that permits APN to prescribe controlled substances is responsible for ensuring that such practitioners are authorized to do so by their State of licensure or registration and for complying with the limitations and restrictions on that authority.
  5. Responsibilities.  Some registered nurses choose to become advanced practice nurses, who often are considered primary health care practitioners and work independently or in collaboration with physicians.  For example, in most States, an APN can prescribe medications.  Advanced practice nurses function as independent primary care practitioners who practice in ambulatory, inpatient, long-term care, and community health settings within the privileges granted by the local governing body.  The four types of APN employed by the IHS are:
    1. Nurse Practitioners.  Nurse practitioners provide basic preventive health care to patients, and increasingly serve as primary and specialty care providers in mainly medically under-served areas.  The most common areas of specialty for nurse practitioners are family practice, adult practice, women's health, pediatrics, acute care, and gerontology; however, there are many other specialties.
    2. Certified Nurse Midwives.  Certified nurse midwives provide primary care to women, including gynecological exams, family planning advice, prenatal care, assistance in labor and delivery, and neonatal care.
    3. Certified Registered Nurse Anesthetists.  Certified registered nurse anesthetists (CRNA) administer anesthesia, monitor patient's vital signs during surgery, and provide post-anesthesia care.  A CRNA administers anesthesia and anesthesia-related care in four general categories:
      1. pre-anesthetic preparation and evaluation;
      2. anesthesia induction, maintenance, and emergence;
      3. post-anesthesia care; and
      4. perianesthetic and clinical support functions.
    4. Clinical Nurse Specialists.  Clinical nurse specialists provide direct patient care and expert consultations in one of many of the nursing specialties.
  6. Scope of Practice.  The APN scope of practice includes, but is not limited to, the following:
    1. Nurse Practitioners.  Nurse practitioners scope of practice includes, but is not limited to, the following:
      1. Works as a licensed, independent practitioner.
      2. Examines patients and establishes medical diagnoses by client history, physical examination, and other criteria.
      3. Orders, conducts, and interprets screening studies, tests, and diagnostic procedures to assess and diagnose problems and establish management/treatment plans.
      4. Initiates consultation, collaboration, and referral requests to specialists and other health professionals.
      5. Teaches, counsels, and advises patients, families, and communities about current health status and illnesses, and provides health promotion and disease prevention services, taking into account age, developmental status, disability, culture, ethnicity, sexual orientation, spiritual/religious affiliation, and lifestyle issues.
      6. Provides appropriate periodic mental health assessments and screening, and counseling for mental illness, family violence, and diseases of addiction.
      7. Prescribes and dispenses medications and durable medical devices and supplies.
      8. Prescribes and dispenses controlled substances within an individual?s Advanced Practice Nurse State license.
      9. Admits, cares for, and discharges patients, when privileged to do so by the employing facility.
      10. Provides culturally competent care with respect to cultural, Tribal, and spiritual beliefs and incorporates ceremonies and practices of the patient belief system into the plan of care.
      11. Practices within specialty area of training and certification only.
      12. Incorporates new procedures and treatment protocols into practice after appropriate training, evaluation of competence, identification of consultation and referral system related to the new procedure, and periodic outcome and competency review.
      13. Practices in accordance with the standards of practice as defined by the American Academy of Nurse Practitioners and/or as outlined by an American professional organization for a specific specialty such as pediatrics, geriatrics, emergency care, etc.
    2. Certified Nurse-Midwives.  A certified nurse midwife scope of practice includes:
      1. Works as a licensed independent practitioner.
      2. Provides health care of women focused primarily on, but not limited to, reproductive health.
      3. Admits and discharges women to health care facilities when privileged to do so by the employing facility.
      4. Orders diagnostic exams, laboratory tests, x-rays, and sonograms.
      5. Analyzes and interprets data, formulates diagnoses, and establishes management/treatment plans.
      6. Provides prenatal, intrapartum, and postpartum care of the low and designated at-risk obstetrical patient.
      7. Manages complicated pregnancies by consultation or collaboration with a physician.  A physician is not always present in rural areas and patient conditions are sometimes managed via phone ?consultation.?
      8. Utilizes written practice guidelines that describe the parameters of service for independent and collaborative midwifery management and transfer of care when needed.
      9. Evaluates fetal well-being in labor.
      10. Evaluates and cares for the newborn, including airway management, resuscitation, and initial examination and well-baby care.
      11. Manages acute, episodic, and chronic conditions occurring in women, referring patients when disease process exceeds provider education, training, and experience.
      12. Prescribes and dispenses medications and durable medical devices and supplies.
      13. Prescribes and dispenses controlled substances within an individual?s certified nurse-midwife State licensure.
      14. Develops health promotion and maintenance plans, including disease prevention and health education counseling.
      15. Provides age-appropriate, periodic physical health screening.
      16. Screens, assesses, treats, and provides health education to patients with gynecological conditions and treats sexually transmitted diseases in women and their contacts.
      17. Provides initial infertility evaluation and referral as appropriate.
      18. Screens and treats for behavioral health problems, including addiction, domestic violence, and depression.
      19. Incorporates new procedures and treatment protocols into practice after appropriate training, evaluation of competence, identification of consultation and referral system related to the new procedure, and periodic outcome and competency review.
      20. Practices in accordance with the standards for the practice of nurse-midwifery, as defined by the American College of Nurse-Midwives.
    3. Certified Registered Nurse Anesthetists.  The Certified Registered Nurse Anesthetists scope of practice includes, but is not limited to, the following:
      1. Works as a licensed independent practitioner.
      2. Performs and documents pre-anesthetic assessment and evaluation of the patient, including requesting consultations and diagnostic studies; selects, obtains, orders, and/or administers pre-anesthetic medications and fluids; and obtains informed consent for anesthesia.
      3. Develops and implements an anesthetic plan.
      4. Selects and initiates the planned anesthetic technique, which may include general, regional, and local anesthesia and intravenous sedation.
      5. Selects, obtains, and administers the anesthetics, adjuvant drugs, accessory drugs, and fluids necessary to manage the anesthetic, to maintain the patient's physiologic homeostasis, and to correct abnormal responses to the anesthesia or surgery.
      6. Selects, applies, and inserts appropriate non-invasive and invasive monitoring modalities for collecting and interpreting patient physiological data.
      7. Manages a patient's airway and pulmonary status using endotracheal intubation, airway adjuncts, mechanical ventilation, pharmacological support, respiratory therapy, or extubation.
      8. Manages emergence and recovery from anesthesia by selecting, obtaining, ordering, and/or administering medications, fluids, or ventilatory support in order to maintain homeostasis, to provide relief from pain and anesthesia side effects, or to prevent or manage complications.
      9. Releases or discharges patients from a post-anesthesia care area and provides post-anesthesia follow-up evaluation and care related to anesthesia side effects or complications.
      10. Orders, initiates and modifies pain relief therapy, through the utilization of drugs, regional anesthetic techniques, or other accepted pain relief modalities, including labor epidural analgesia.
      11. Prescribes and dispenses controlled substances as authorized by an individual's Certified Registered Nurse Anesthetists State licensure.
      12. Responds to emergency situations by providing airway management, administering of emergency fluids or drugs, and using basic or advanced cardiac life support techniques.
      13. Initiates consultation, collaboration, and referral requests to specialists and other health professional when disease process exceeds provider education, training, and experience.
      14. Performs additional nurse anesthesia responsibilities, which are within the education, training, and expertise of the individual Certified Registered Nurse Anesthetists.
      15. Practices in accordance with the American Association of Nurse Anesthetists Scope and Standards for Nurse Anesthesia Practice.
    4. Clinical Nurse Specialists.  Clinical nurse specialists may be covered under these scopes of practice only if they are also licensed as nurse practitioners.