Held to highest license?

Nurses General Nursing

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I have been informed, that when employed in healthcare, one is held to their highest licensure. That is, an RN is legally held to the standards of that license, even if employed as an LVN ... A risk management nightmare (and a huge liability for the nurse). How do these rules apply to roles without a license - such as CNAs or HHAs/caregivers? Are the standards different in the hospital versus the home environment? I see the LOGIC behind this from a risk management standpoint, I just wonder about the legal basis.

Would someone be kind enough to direct me to information on these legalities? This is something I would like to verify and understand. Is this something from the BRN/BON in each state? I have been unable to extract it from the Nurse Practice Act in mine.

I have posted this on my state board with no response. Any insight would be greatly appreciated.

Hello all! I'm newly registered here. I have a similar question. I've recently taken a job as a caregiver while I look for a LVN job. We do in home non-medical care and we are told that we DO NOT pass meds, only giving med reminders. Then I'm given a hospice pt and told that on some occasions he may need morphine, per the hospice nurse. I understand that the family can do that etc. but since I'm a nurse, not employed by them as a nurse, can I administer the morphine? The admin there told me when I voiced my concern, "well, you're a nurse wherever you go". But will that get me in trouble with my license since I'm not employed in that capacity?

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Hello all! I'm newly registered here. I have a similar question. I've recently taken a job as a caregiver while I look for a LVN job. We do in home non-medical care and we are told that we DO NOT pass meds, only giving med reminders. Then I'm given a hospice pt and told that on some occasions he may need morphine, per the hospice nurse. I understand that the family can do that etc. but since I'm a nurse, not employed by them as a nurse, can I administer the morphine? The admin there told me when I voiced my concern, "well, you're a nurse wherever you go". But will that get me in trouble with my license since I'm not employed in that capacity?

If you are employed as a caregiver, you can not legally exceed the scope of a caregiver. Do not do it. This is why it is not recommended to work as a CNA, HHA, PCT, or caregiver, when one holds a valid nursing license. The very point that my instructor in school was making so many years ago. But the fine line here: you are employed by an agency as a "caregiver". If, instead, you are privately employed by the patient, or patient's family (paid out of their pocket), and no agency (third party employer) is involved, you can do whatever you and the client agree upon. A very fine line.

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"Hello all! I'm newly registered here. I have a similar question. I've recently taken a job as a caregiver while I look for a LVN job. We do in home non-medical care and we are told that we DO NOT pass meds, only giving med reminders. Then I'm given a hospice pt and told that on some occasions he may need morphine, per the hospice nurse. I understand that the family can do that etc. but since I'm a nurse, not employed by them as a nurse, can I administer the morphine? The admin there told me when I voiced my concern, "well, you're a nurse wherever you go". But will that get me in trouble with my license since I'm not employed in that capacity?"

Please do not do this! I think you have the instinct this is WRONG and it is. The idea that you are a nurse "wherever you go" is administration trying to take advantage of your license. Legally, you must function within the scope of practice that your position entails. A nurse administers medications based on MD's orders? How would you administer without an order? Who would be responsible if something adverse occurred? Also, this patient being on hospice, brings in a special set of concerns. Administering a dose that may contribute to the patient's demise may be appropriate, but do you want to be the one to administer it and then defend it in court when the family "changes their mind"?

This is exactly the type of situation that made me ask this question. I never want to put myself in such a quandry. In your exact position, I would respectfully refuse, and leave the job if necessary. It is the more subtle but serious situations that make me wonder what course of action I would take. "What if?" I see a family doing wound care improperly or administering medications inappropriately? Notice a symptomatic electrolyte imbalance? I could write a list a mile long and as previously stated, I do not have the right to sit before the BRN and say "well, I was practicing as a HHA." Your employer knows this and I would bet would sell your right up the river if something were to go awry.

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Specializes in NeuroICU/SICU/MICU.

I have several classmates who were employed as PCTs prior to graduation, and who have continued working as PCTs after passing boards and becoming licensed. I'm glad they're employed in this economic climate, but I do worry for their licenses for all the reasons discussed here. I hope the hospital ends their hiring freeze soon, so they (and I!) can start working to our full potential.

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Are you sure one is held to their "highest licensure" and what exactly does that mean?

I work with several advanced practice nurses (CNMs, WHNPs, ANPs) who work as RNs on the unit upon which I work. It has never been a problem.

I also know of a hospital network that will hire new grad RNs to work as CNAs until an RN position opens up.

I imagine it depends entirely on each state.

It does. That is why I think this question is so hard to answer. Some states do not allow dual licenses, some do. Some hold you to the highest licenses, some hold you to the job title you were hired for. The best bet is to call the BON in your state. But it sounds like the OP did this and didn't get any response yet.

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Are you sure one is held to their "highest licensure" and what exactly does that mean?

I work with several advanced practice nurses (CNMs, WHNPs, ANPs) who work as RNs on the unit upon which I work. It has never been a problem.

I also know of a hospital network that will hire new grad RNs to work as CNAs until an RN position opens up.

I imagine it depends entirely on each state.

Well, it's not a problem until something goes wrong enough to end up in court. V. few state BONs have rules which specifically prohibit nurses working "below" their level of licensure (although I'm told some do), but the courts across the US consistently hold licensed individuals to the practice standards of their highest level of education/licensure, regardless of what title they were working under at the time of whatever incident occurred. If you are licensed as an RN and take a job as a CNA or LPN, you don't get to forget what you know and neglect to intervene appropriately to keep people safe just because you have a different job title. The conflict between the scope of practice for the position, per your employer, vs. the scope of practice for your licensure is why lots of employers (the smart ones) just won't allow people to work below their highest level of licensure. Other employers, as already noted, are glad to take advantage of you for a CNA salary ...

My new NC BON bulletin just arrived the other day, and coincidentally included an article on this topic (in response to the many questions the BON is getting about this, it said) which includes this statement:

"... It is important for the NA who also maintains a nursing license to remember that, although they are functioning in the role of an unlicensed person, they remain accountable for their nursing knowledge and skill. ..."

This issue of the Bulletin is not on the NC BON website yet (I just checked :)), but the quote above (and the entire article) is from pg. 30 of the Summer '10 NC BON Bulletin. And if you do an online search, you can find similar official statements from many other BONs over the years. Most BONs, while not specifically prohibiting this, are on record as cautioning that they think it's a really bad idea. Sometimes ya gotta do what ya gotta do -- but, IMO, it's important for nurses to understand the risks and ramifications of doing this.

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Hello all! I'm newly registered here. I have a similar question. I've recently taken a job as a caregiver while I look for a LVN job. We do in home non-medical care and we are told that we DO NOT pass meds, only giving med reminders. Then I'm given a hospice pt and told that on some occasions he may need morphine, per the hospice nurse. I understand that the family can do that etc. but since I'm a nurse, not employed by them as a nurse, can I administer the morphine? The admin there told me when I voiced my concern, "well, you're a nurse wherever you go". But will that get me in trouble with my license since I'm not employed in that capacity?

So did you tell the admin that you should get paid as a nurse, too, if they take that stance?

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Thanks to all who replied. Just reading these has confirmed what I DID have a feeling about, but wasn't sure. I haven't had the situation come up yet where the client needed morphine while I was there, but I had pretty much decided that if he needs it, I'll call his daughter who lives a minute away. If she can't come then the hospice nurse will need to do it.

And yes, in the beginning, I told my daughter that if they were going to keep referring to me being a nurse then they need to pay me nursing pay. ;)

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My hospital will float nurses to other units to act as PCAs if the need arises.

I'm not quite sure I understand why someone who is permitted in their state to work below their level of licensure would be concerned about doing so due to being held to the standards of the higher license. If you are hired as a PCA, I would hope that even in that capacity if you saw something wrong with the pt you would assist the nurse rather than walk away saying "I'm just a PCA." If you are a PCA and get a crazy low bp on a pt but the nurse refuses to act, it's not like you can take it upon yourself to give the pt a fluid bolus (requires an order where I work) or call the doctor but I would hope you'd at least put their feet up and move the info up the chain of command. Same thing for a pt with chest pain, you can't give them meds but I'd hope let the CN/NM/supervisor/whoever know the primary nurse is refusing to treat it (and maybe stick some O2 on the pt if available). Anyone in our facility can call the MET/Rapid Response Team so that's always an option as well.

Could someone offer me a scenario demonstrating why one should be concerned? I'm obviously missing something here. Perhaps it would be different in a setting other than the hospital where we always have someone else to go to should the situation get beyond our control (true for a PCA as well as a nurse).

I understand not administering meds as a home health aide/caregiver role and I wouldn't do it either. Again though, should a situation arise I would contact the family or nurse so they could handle it. If they refused and I felt the situation warranted it, I'd call 911.

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