Scope and Standards of Practice for Moderate Sedation from the Perspective of the Registered Nurse

Providers of moderate sedation include board-certified anesthesiologists and certified registered nurse anesthetists as well as non-anesthesia providers such as registered nurses (RNs), respiratory therapists, gastroenterologists, and emergency physicians (to name a few). In this article, we discuss the scope and standards of practice from the perspective of RNs.

During the initiation of moderate sedation in the 1980s, RNs administered a benzodiazepine, such as diazepam, and/or a narcotic like meperidine to control and manage the patient’s pain versus sedation. In addition, RNs conducted assessments and monitored parameters during the procedure, including blood pressure, heart rate, and respiration, during 15-30-minute intervals.  

Identifying an acceptable standard of care by RNs when administering moderate sedation is challenging. However, there is an expectation that non-anesthesia providers should have the same standard of care as anesthesia personnel, and patients must not receive a worse level of care. RNs that monitor and/or administer moderate sedation and analgesic medications must demonstrate competence and deliver services within the acceptable scope of practice and not advance administration of sedation that requires advanced anesthesia care, which may result in the patient experiencing a level of deep sedation or general anesthesia. 

State Boards of Nursing

State nursing boards provide a foundation for guidance as RNs define and refine their roles as non-anesthesia providers. Several state nursing boards developed advisory opinions, position statements, declaratory rulings, and/or guidelines to determine the capability, experience, and competence of RNs to provide safe patient care during moderate sedation. This response helped prevent inappropriately using untrained or inexperienced nursing staff for moderate sedation agent administration. Each State Nursing Board will focus on the patient’s safety and welfare and define RNs’ scope of practice as non-anesthesia providers. 

RNs rely on or request State Nursing Boards and other administrative authorities to define a standard of care and policy and procedures to guide their scope of practice. Therefore, each RN must continually review updated or new information their state nursing board provides. 

Each state identified the following guidelines that the non-anesthesia provider RN must follow when administering moderate sedation:

• The definition of moderate sedation.

• Information such as declaratory rulings, position statements, advisory opinions, guidelines, policy statements, or FAQs as put forth by state nursing boards.

• The scope of practice for educated and competent non-anesthesia RNs, who may administer and monitor moderate sedation and analgesia. 

• Some states allow competent and educated RNs who are not Certified Registered Nurse Anesthetists (CRNAs) to administer propofol for sedation within their scope of practice.

Standards of Practice

State Nursing Boards statutes, professional organization position statements, guidelines, recommended practices, literature review, and institution practices develop non-anesthesia RN moderate sedation standards of practice. However, RNs must acknowledge that institutional practices often fall under professional organizations’ national standards determining malpractice and negligence in law courts. 

The American Nurses Association (ANA) identified the need for nursing standards in the 1960s and published the first generic nursing standards in 1973 for every RN. Revisions of nursing standards occurred over the next couple of decades and collaborated with specialty nursing organizations to develop specialty nursing standards criteria. 

A standard identifies the expected level of nursing care without variation and reflection of the same judgment between nurses. Standards provide a nursing profession authoritative statement about the responsibilities and accountability of nurses. Professional nursing organizations develop and disseminate acceptable standards of practice. 

Position Statements

Specialty nursing organizations, State Nursing Boards, and other professional associations, including expert panels, develop position statements about actual or emerging practice trends based on a professional consensus. Position statements are based on current practice trends and safe implementation and developed from an area of detrimental patient safety concerns. 

Published in 1992, the “Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures” is the final position statement for all RNs managing moderate sedation and analgesia patients. In addition, many State Nursing Boards, state nursing associations, and specialty nursing associations support the position statement today or reference it when requesting nursing practice opinions for moderate sedation. 

Practice Guidelines

Practice guidelines are systematically developed recommendations to assist practitioners in making patient decisions about their health care. The development guidelines require practice guidelines to be science-based, documented, unbiased, and clear. Historically, the National Guideline Clearinghouse (NGC) provided a detailed and comprehensive database of evidence-based practice guidelines and other related documents to disseminate, implement, and use clinical practice guidelines. 

While many medical professional organizations offer guidance around moderate sedation and analgesia, the “gold standard” practice guidelines are considered to be the “Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology”.  

These guidelines aim to “provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert, and practitioner opinion, open forum commentary, and clinical feasibility data.” The authors clearly indicate that the guidelines are aimed to provide guidance — they aren’t meant to be interpreted as standards or requirements put forth by an authority, institution, or organization.

Recommended Practices

Recommended practices include technical and professional perioperative nursing performance criteria based on current nursing practice, scientific data, and agency standards and regulations to recommend nursing practice guidelines. 

Standard of Care Development

The standard of care is developed on guidelines, position statements, and recommended practices. Each institution should consider the following when developing a standard of care for RNs responsible for administering moderate sedation and analgesia. 

• Identify the RNs’ scope of nursing practice by contacting the State Nursing Board to determine specific allowable administration of medications or special conditions or criteria.

• Retrieve position statements, guidelines, and recommended practices for RNs administering moderate sedation and analgesia.

• Review the standard of care the patient receives during the administration of moderate sedation and analgesia.

• Assess if a consistent standard of care exists between institutional departments administering moderate sedation and analgesia. 

Defining training and education needs often plays a crucial role in the standard of care development. Online interactive courses like Safe Sedation Training provide standardized training to all moderate sedation team members and can help organizations define a standard of care by delivering rationale-based training and monitoring standards. In addition, such training will ensure all departments that provide moderate sedation provide consistent care to all patients under similar conditions by ensuring all team members receive uniform training.