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Who can be called a “nurse“? or this column, I would like to address the legalities of a F question that was sent to me.

Question: I am a member of AORN and wish to ask a 1egaVethical question. I am an employee of a surgery center that is part of a clinic. I recently wit- nessed a surgeon’s office/surgical assistant introduce herself to a patient’s family member as the physician’s nurse. This person is not a nurse. She is a certified sur- gical technician, but the physician frequently refers to her as his “nurse.” When I asked her why she identified herself as a nurse, she stated that it was “just easier that way.” I am a registered nurse who worked very hard to obtain my license. Is this legally correct? Is this ethical?

Answer: Such a straightforward question. Unfortunately as is true with most questions about legali- ties, who may legally refer to themselves as nurses does not always have so straightforward an answer.

LEGALLY CORRECT7 Whether people who are not

licensed as registered, practical, or vocational nurses may refer to themselves as “nurses” depends on the language of their states’ nurse practice acts and/or the rules of the board of nursing. Most states, though not all, have restricted the use of the titles of nurses.

Part of the issue is that the word nurse has, in common usage, described people who are

not licensed so that the definition of the word is broader than “a per- son licensed to practice nursing” (eg, a child’s nurse, which refers to someone who takes care of a child). So, although most states have restricted the use of the title “registered nurse,” many are silent on the use of the title “nurse.”

Many states have restricted the use of titles or acronyms to those who are licensed as nurses. Each state has a different way of addressing title protection, and the slightest difference in the lan- guage can make a difference as to whether office assistants who are not licensed nurses can legally refer to themselves as nurses. Several examples follow of lan- guage from various states’ nurse practice acts.’

If the author of this question lives in Nebraska, the answer is straightforward. The Nebraska Nurse Practice Act, Section 7 1 - 1 132.17. states

In the interest of public safety and consumer aware- ness, it is unlawfil for any person to use the title nurse in reference to himself or herself in any capacity, except individuals who are or have been licensed as a registered nurse or a licensed practical nurse.

Thus, an office assistant who identifies herself as the physi- cian’s nurse in Nebraska would be in violation of this law.

Many states have language

akin to the following examples.

No person shall. . . use the title “registered nurse,” the initials “RN,” or any other title implying the person is a registered nurse . . . with- out holding a current, valid license as a registered nurse. Ohio Revised Code Section 4723.03( A).

Only registered nurses shall use that title, the abbrevia- tion RN or any other words, letters, signs, or figures indicating that the person using the same is a regis- tered nurse. Delaware Nurse Practice Act: Subsection 1920(d).

It shall he unlawful for any person . . . to represent in any way that such person is a registered nurse or to use afer his or her name the abbreviation “ R N ’ unless the person holds an effec- tive, unsuspended license or is a professional nurse . . . New Jersey Nurse Practice Act Section 45: 1 1 -37(c).

Another twist on such statutes are states whose nurse practice acts state that only licensed nurses are allowed to use the title and prohibit its use by anyone else. For example, the Georgia Nurse

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Practice Act Section 43-26-6(a) states

Any person who is licensed as a registered professional nurse shall have the right to use the title “registered pro- fessional nurse” and the abbreviation “RN.” No other person shall assume such title or use such abbreviation or use any other words, letters, signs, or symbols to indicate such person is a registered nurse in Georgia.

Washington has a similar pro- vision but chooses to provide the protection to “registered nurse” (rather than Georgia’s “registered professional nurse”):

A person who holds a license to practice as a reg- istered nurse in this state may use the title “registered nurse” and the abbrevia- tion “RN.” No other person m y assume this title or use the abbreviation or any other words, letters, signs, or figures to indicate the person using them is a reg- istered nurse. RCW 18.79.030( 1)

In states with this type of lan- guage, it could be argued that even though the statute expressly does not forbid an unlicensed per- son from using the title “nurse,” the use of the word falls into the category of “any other title” or “any other words” or “represent in any way” such that its use by an office assistant would be unlawful.

of the specific titles they are reserving to the licensed nurse

1

Other states are more inclusive

only. Examples include

No person shall . . . use any words, abbreviations, f ig - ures, letters, title, sign, or device tending to imply that he or she is a registered professional nurse includ- ing the title or initials “Registered Nurse,” “Professional Nurse,” “Registered Professional Nurse,” “Certified Nurse,” “Trained Nurse,” “Graduate Nurse,” “PN,” or “RN,” or “RPN,” or similar titles or initials with intention of indicating reg- istered professional nurse. Illinois Nurse Practice Act Section 6(e).

or,

Unless licensed as a regis- tered nurse . , , no person shall , . . use the title “reg- istered nurse,” “profession- al nurse,” “professional registered nurse,” or the abbreviation “RN,” or any other abbreviation thereof or use any other title, abbreviation, letters, f ig- ures, signs, or devices to indicate that the person is a registered nurse. New Mexico Nurse Practice Act: Section 6 1 -3-5(A)(2).

In these examples, it is less clear that an office assistant is prohibited from using the term nurse. As the legislatures in these states have chosen to specifically prohibit the use of several titles in addition to that of “registered nurse” or “RN,” it can more plau- sibly be argued that if they had intended to include prohibition of “nurse,” they would have done so.

So even though the statute includes the clause referring to prohibition of all other titles to indicate the person is an RN, the prohibited titles arguably may not include the title “nurse” itself. Such an argument would be par- ticularly persuasive in states such as New Mexico, where the law had been amended to add “profes- sional registered nurse” to the already prohibited “registered nurse” or “professional nurse.” In these states, whether the office assistant can use the term “nurse” will directly depend on whether the intent of the use of the term is to indicate she is or practices as a registered nurse. In the AORN member’s question, the office assistant did not seem to intend to represent herself as a registered nurse, given the reason for her doing so was that it was “just eas- ier that way.”

To find out whether nonregis- tered nurses may refer to them- selves as nurses in your state, con- tact your state board of nurses. If use of the title “nurse” is not allowed, the state board can pro- vide further information about steps to take to enforce the law.

ENFORCEMENT Just as states differ in whether

and how they restrict use of titles applicable to nurses, so too do they differ in how they enforce any such prohibition if they do have it. Some states will make unauthorized use of a title refer- ring to an RN a misdemeanor; others may simply label it as unlawful or unprofessional con- duct. Some states extend their enforcement to the employer of the person, or to any other per- son who aids or abets the mis- representation, and makes such action a misdemeanor (in some

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cases, it may be considered a felony). Depending on the state, violation of any applicable title protection provision in a nurse practice act can result in a fine or criminal conviction of not only the person using the unau- thorized title but also of others who employ or otherwise aid or abet the unauthorized use. So, in the example posed in the mem- ber’s question, it is possible that not only is the office assistant acting unlawfully, but so too is the physician who refers to her as his nurse and/or the employer who allows her to use the term. This is assuming, of course, the state prohibits use of the term “nurse” in the first place.

IS IT ETHICAL? Even in those states where it

may be legal to identify oneself as a nurse when one is not a licensed nurse, a question of its ethical efficacy arises. Clearly, where its unauthorized use is intended to mislead or deceive the public, it is unethical because veracity, or truth-telling, is a recognized ethi- cal principle. In the situation described, it may be that neither the physician nor the assistant intends to represent the assistant as a professional nurse; it may be an easy way of referring to some- one (usually female) who works

NOTES

with a physician. In this case, the ethical analysis would proceed to balance the ease against the potential of patients’ and family members’ being misled to believe the assistant is a professional nurse, regardless of the intent. As the Nebraska legislature succinct- ly stated, the issue is “public safe- ty and consumer awareness.”

SUGGESTIONS If the state board allows the use

of the term nurse or has not taken a position on the issue, contact the applicable state nurses association to learn if they have taken a posi- tion and/or are lobbying to get such a prohibition into statute or board of nursing rules. Some state nurses associations will write to people who are using the title inappropriately to inform them (and their employers) of the possi- ble ethical and legal (if applicable) ramifications if they continue to do so. This is definitely not an issue unique to perioperative nurs- es. Inappropriate use of the title is a concern of all registered nurses. One state nurses association has even encountered a situation in which veterinarians wanted to call their assistants nurses!’

This issue is not limited to nurs- es who practice in the United States. The International Council of Nurses (ICN) adopted a 1995 posi-

tion statement that states, in part,

Persons receiving care have a right to know the qualiji- cation and competence of the health personnel they are dealing with and have confidence in that compe- tence. Titles convey this message, and the title nurse serves that purpose for the nursing profession interna- tionally and nationally . . . While recognising that nurs- ing has [developed] and will continue to develop its range and specialities in response to the changing health needs of the popula- tion, the ICN reajirms the importance of retaining the title nurse with all the impli- cations of accountability for the quality of care that this title endows on its holders.=

ELLEN K. MURPHY RN, JD, FAAN

UNIVERSITV OF WISCONSIN, MILWAUKEE SCHOOL M NURSING

All nurse practice acts quoted here were accessed via the National Council of State Boards of Nursing web site (www.ncsbn.org) and may have undergone subsequent revision. As citation here is for purposes of example only, language was not ver- ified for current accuracy.

2. “The title of nurse.” International Council of 1 . G D Champion, personal communication with the Nurses Position Statement. Available from

http://www.icn.ch/pstitle.htm. Accessed 14 January 1999. author, Milwaukee, 22 January 1999.

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