Scope of Practice and Professional Boundaries in Infusion Therapy

Defines the regulatory hierarchy governing clinician scope of practice, establishes the framework for practice expansion and delegation of vascular access tasks, and delineates the professional roles and responsibilities of all personnel involved in infusion therapy.

policies•Jan 2026•Professional Practice

Scope of Practice and Professional Boundaries in Infusion Therapy Policy

1. Policy Statement

It is the policy of this organization that every clinician involved in the prescription, insertion, management, or removal of vascular access devices shall operate strictly within their legally defined scope of practice as determined by the applicable legislative, regulatory, and organizational authority. No individual shall perform a vascular access procedure or infusion therapy task for which they lack legal authorization, documented competency, and organizational approval. Delegation of vascular access tasks shall comply with the Five Rights of Delegation and shall never transfer professional clinical judgment to unlicensed or unqualified personnel.

2. Purpose

This policy exists to:

  • Protect patients from harm by ensuring that only legally authorized, competently trained, and organizationally credentialed clinicians perform vascular access procedures appropriate to their professional designation.
  • Establish a clear, enforceable framework for determining when a clinician may expand their practice to adopt new vascular access skills or technologies.
  • Define the principles, requirements, and prohibitions governing the delegation of infusion therapy tasks to subordinate or unlicensed personnel.
  • Delineate the specific roles, responsibilities, and accountability structures for all professional categories involved in vascular access care, including Registered Nurses, Licensed Practical/Vocational Nurses, Advanced Practice Registered Nurses, Vascular Access Specialists, Physicians, and Unlicensed Assistive Personnel.
  • Reduce organizational legal liability by ensuring that all vascular access activities are conducted within the boundaries of applicable law, regulation, and institutional credentialing.

3. Scope

This policy applies to:

  • All employees, contracted staff, agency personnel, students, and volunteers who participate in any aspect of vascular access or infusion therapy within this organization.
  • All professional categories, including but not limited to: Registered Nurses (RNs), Licensed Practical/Vocational Nurses (LPN/LVNs), Advanced Practice Registered Nurses (APRNs), Certified Registered Nurse Anesthetists (CRNAs), Physician Assistants (PAs), Physicians (MDs/DOs), Vascular Access Specialists, Infusion Nurse Specialists, Medical Assistants (MAs), and Unlicensed Assistive Personnel (UAPs).
  • All clinical settings within the organization, including inpatient units, emergency departments, perioperative areas, ambulatory infusion centers, home health services, and affiliated outpatient facilities.
  • All vascular access procedures, including but not limited to: peripheral IV insertion and removal, PICC insertion and management, central line assistance, blood specimen collection from vascular access devices, infusion pump programming, medication administration via vascular access, dressing changes, and catheter flushing and locking.

4. Policy Requirements

4.1 The Regulatory Hierarchy

4.1.1 Clinicians shall recognize and comply with the following hierarchy of regulatory authority, listed from highest to lowest legal weight:1

Level 1 — Legislative Authority. Statutes and laws enacted by the applicable jurisdiction (federal, state, or provincial), including but not limited to Nurse Practice Acts, Medical Practice Acts, and Pharmacy Practice Acts. Legislative authority constitutes the highest level of legal mandate and cannot be overridden by any lower-level authority.

Level 2 — Regulatory Rules. Specific regulations promulgated by professional licensing boards (e.g., State Boards of Nursing, State Medical Boards) to implement and enforce legislative mandates. These rules define the permissible scope of activities for each license type.

Level 3 — Interpretive Guidelines. Operational documents, advisory opinions, and position statements issued by regulatory bodies to clarify how regulations should be applied in daily clinical practice.

Level 4 — Professional Standards. Evidence-based clinical guidelines and position statements published by recognized professional organizations (e.g., Association for Vascular Access [AVA], American Nurses Association [ANA], Society of Interventional Radiology [SIR]).23456

Level 5 — Organizational Policy. Institutional policies, procedures, and protocols that further define the permissible activities of clinicians within the specific practice setting.

Level 6 — Transnational Agreements. International protocols, reciprocity agreements, or cross-border credentialing standards that may influence the recognition of foreign credentials or the practice of clinicians with international licensure.

4.1.2 Conflict Resolution. In the event of a conflict between levels of the hierarchy, the more restrictive standard shall prevail. Organizational policy may restrict but shall never expand a clinician’s scope beyond what is permitted by legislative or regulatory authority.

4.1.3 Critical Prohibition. Practicing outside of one’s defined legal scope—regardless of clinical proficiency, years of experience, or organizational need—constitutes unsafe practice and exposes the clinician to significant legal liability, regulatory action (including license revocation), and organizational disciplinary consequences up to and including termination.

4.2 Decision-Making Framework for Practice Expansion

4.2.1 As vascular access technology and clinical needs evolve, clinicians may be asked to perform tasks that were not part of their initial training or traditional scope (e.g., an RN inserting a CVAD, a UAP inserting a peripheral IV, an LPN managing a PICC). Before any individual adopts a new vascular access skill, all six of the following criteria must be affirmatively met and documented:789

CriterionRequirementDocumentation
LegalityThe governing licensing body expressly permits this activity for the clinician’s license typeWritten verification from regulatory body or legal counsel on file
EvidenceThe practice is supported by current, peer-reviewed clinical research demonstrating safety and efficacyLiterature citations in training materials
PolicyA written organizational protocol exists that specifically authorizes this activity for the clinician’s roleApproved protocol on file with effective date
EducationThe clinician has completed formal, specialized training for this specific taskCertificate of completion or training transcript
CompetencyDocumented validation of the clinician’s technical skill and safety exists, including direct observation by a qualified evaluatorSigned competency validation form
AccountabilityThe clinician acknowledges and accepts full professional responsibility for the outcome of the procedureSigned acknowledgment on file

4.2.2 The Clinical Education Department, in collaboration with the Vascular Access Governance Committee, shall maintain a Practice Expansion Matrix that maps each vascular access task to the professional roles authorized to perform it within this organization, along with the specific competency requirements for each.

4.2.3 No clinician shall be coerced, pressured, or required to perform a vascular access procedure that falls outside their documented competency or comfort level, even if the task is within their legal scope. Clinicians who decline to perform a procedure for these reasons shall not face disciplinary action but shall be directed to appropriate training and competency validation opportunities.

4.3 Principles and Requirements of Delegation

4.3.1 Definition. Delegation is the transfer of responsibility for the performance of a specific vascular access task to a qualified individual while the delegating clinician retains ultimate accountability for the patient outcome. Delegation is a professional privilege, not a right, and must be exercised with clinical judgment.

4.3.2 The Five Rights of Delegation. All delegation of vascular access tasks shall comply with the following framework:

Right Task. The activity delegated must be routine, predictable in outcome, and does not require professional clinical judgment during its execution. Tasks that require ongoing assessment, nursing judgment, or complex decision-making at the point of care are not delegable.

Right Circumstances. The patient must be clinically stable and the clinical context must be appropriate. Delegation is not appropriate in emergent, rapidly changing, or unpredictable clinical situations.

Right Person. The delegate must hold documented competency for the specific task, possess the legal authority to perform it in the applicable jurisdiction, and must have been verified by the delegating clinician as appropriate for this specific patient encounter.

Right Direction. The delegating clinician shall provide clear, concise, and specific instructions, including the expected outcome, parameters for reporting, and conditions under which the delegate must stop and seek assistance.

Right Supervision. The delegating clinician shall directly or indirectly monitor the delegated activity, be available for questions and intervention, and evaluate the results of the completed task.

4.3.3 Prohibitions on Delegation. The following vascular access activities shall never be delegated to unlicensed personnel or to individuals whose license does not expressly authorize them:

  • Initial patient assessment for vascular access needs or device selection.
  • Clinical evaluation of a patient’s response to infusion therapy or a new medication.
  • CVAD insertion, removal, or troubleshooting of complications.
  • Interpretation of diagnostic data related to vascular access (e.g., chest X-ray for tip confirmation).
  • Patient and family education regarding complex self-management of vascular access devices.
  • Any task that requires the exercise of professional clinical reasoning or nursing judgment during its performance.

4.3.4 Documentation of Delegation. Every instance of delegation shall be documented in the patient’s health record, including: the task delegated, the name and credentials of the delegate, the supervision provided, and the outcome of the delegated task.

4.4 Professional Roles and Responsibilities

4.4.1 Registered Nurses (RNs). The RN is the cornerstone of infusion therapy delivery, exercising clinical judgment to integrate assessment data, plan vascular access care, implement evidence-based interventions, and evaluate patient outcomes. RNs shall advocate for “top-of-license” practice, ensuring that organizational barriers do not unnecessarily restrict their evidence-based capabilities.1011 Within this organization, RNs are authorized to perform peripheral IV insertion and removal, administer medications and infusions via all authorized access devices, perform CVAD dressing changes and maintenance, assess vascular access sites, initiate DIVA escalation protocols, and delegate appropriate tasks to qualified subordinate personnel.

4.4.2 Licensed Practical/Vocational Nurses (LPN/LVNs). The scope for LPN/LVNs varies significantly by jurisdiction. Within this organization, LPN/LVNs are authorized to perform only those vascular access tasks expressly permitted by the applicable State Board of Nursing and further approved by organizational policy. The Clinical Education Department shall maintain a current LPN/LVN Vascular Access Scope Matrix that reflects the most recent regulatory guidance.1213 At minimum, all LPN/LVN vascular access activities shall be performed under the supervision of an RN or physician, as defined by state regulation.

4.4.3 Advanced Practice Registered Nurses (APRNs). APRNs, including Nurse Practitioners (NPs) and Certified Registered Nurse Anesthetists (CRNAs), may hold prescriptive authority and may be authorized to perform advanced vascular access procedures within their legal scope.1415 Within a facility, the APRN’s practice is further governed by Credentialing and Privileging—specific permissions granted by the Medical Staff Office and approved by the governing board to perform defined interventions.161718 APRNs shall not perform any vascular access procedure for which they have not been expressly privileged, regardless of their legal scope.

4.4.4 Vascular Access Specialists and Infusion Nurse Specialists. Clinicians who hold board certification in infusion therapy (e.g., CRNI®, VA-BC™) serve as vital organizational assets.19 Their organizational role includes: leading quality improvement initiatives to reduce catheter-related bloodstream infections (CRBSIs), providing expert consultation for difficult access cases and complex infusion regimens, drafting and revising the evidence-based protocols and standards that guide institutional practice, serving as clinical preceptors and competency evaluators for vascular access training programs, and participating in product evaluation and technology adoption decisions.202122

4.4.5 Physicians (MDs/DOs) and Physician Assistants (PAs). Physicians and PAs perform vascular access procedures within the scope of their medical licensure and institutional privileges.23 They are responsible for prescribing vascular access devices, interpreting diagnostic imaging for catheter tip confirmation, and managing complex procedural complications. Collaborative practice with nursing and vascular access specialist teams is expected.

4.4.6 Unlicensed Assistive Personnel (UAPs) and Medical Assistants (MAs). UAPs and MAs may perform only those vascular access tasks expressly permitted by the applicable state law and organizational policy.2425262728293031 In all cases, their activities are limited to technical tasks with predictable outcomes, performed under the direct or indirect supervision of a licensed clinician.32 UAPs and MAs bear accountability for the technical completion of the delegated task only; clinical accountability remains with the supervising licensed clinician.

5. Compliance

5.1 Monitoring. Compliance with this policy shall be monitored through annual credential and licensure verification for all clinical personnel (managed by Human Resources and the Medical Staff Office), annual competency validation reviews for all personnel performing vascular access tasks, concurrent clinical observation audits by Charge Nurses and Vascular Access Specialists, retrospective delegation documentation audits (conducted quarterly by the Quality Department), and review of adverse events and near-misses related to scope-of-practice concerns.

5.2 Key Performance Indicators.

  • Percentage of clinical staff with current, verified licensure and credentials on file (target: 100%).
  • Percentage of vascular access personnel with current competency validation on file (target: 100%).
  • Number of identified scope-of-practice violations per reporting period.
  • Delegation documentation compliance rate.

5.3 Enforcement. Practicing outside of one’s legal scope constitutes a serious violation of this policy and may result in immediate suspension of clinical privileges pending investigation, report to the applicable professional licensing board, progressive disciplinary action up to and including termination, and exclusion from future vascular access activities. Improper delegation resulting in patient harm shall be investigated through the organization’s root cause analysis process, with accountability assigned to both the delegate (for task execution) and the delegator (for the decision to delegate and the adequacy of supervision).

6. Exceptions

6.1 Exceptions to this policy may be granted only in the following circumstances:

  • True medical emergencies where the immediate preservation of life or limb requires a clinician to perform an action outside their typical organizational authorization (but still within their legal scope). The clinician shall document the emergent circumstances, the actions taken, and the clinical rationale within twelve (12) hours.
  • Formal exception requests shall be submitted to the Vascular Access Governance Committee and the Chief Nursing Officer jointly. No exception shall be approved that permits a clinician to practice outside their legal scope as defined by legislative or regulatory authority.

6.2 Approved exceptions are time-limited (maximum six months), require a mitigation plan, and must be re-evaluated before renewal.

  • SOP-VA-020: Delegation of Vascular Access Tasks: Procedure and Documentation
  • SOP-VA-021: Practice Expansion Approval Process
  • POL-001: Foundations of Clinical Practice and Specialized Population Management
  • POL-007: Competency and Competency Validation in Vascular Access
  • LPN/LVN Vascular Access Scope Matrix (maintained by Clinical Education)
  • Practice Expansion Matrix (maintained by Vascular Access Governance Committee)
  • Applicable State Nurse Practice Act and Board of Nursing Regulations
  • Applicable State Medical Practice Act
  • American Nurses Association (ANA) Principles of Delegation
  • Joint Commission Human Resources Standards (HR.01.02.01 et seq.)
  • Organizational Credentialing and Privileging Policy
  • Organizational Progressive Corrective Action Policy

8. Revision History

VersionDateAuthor(s)Description of Change
1.02026-02-01D. Woo, M. Stern, I.M. WrightInitial policy creation and approval
———Scheduled review date: 2027-02-01 or upon change in applicable state regulation, whichever occurs first

References

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