Is 'scope of practice' not taught in school?

tuahla · Feb 27, 2012

I'm in my second semester, and while I've heard a little about the scope of practice, have yet to be taught anything conclusive. I've looked it up for my state and it seems very vague. One of my instructors did tell us a story about how she had to refuse to do something because it wasn't in her scope of practice...my question is how did she know?

ChristinP · Feb 27, 2012

i live in connecticut - good luck to anyone in search of an in depth scope of practice! there is not a list of do's and don'ts.

we were taught what we could and could not do in school- with an emphasis on what we could not do.

i've met many lpns who have no clue as to what they really can and cannot do.

this is what i have to go by from the state of connecticut:

in january 1989, the board made the following findings of fact:

1. the lpn is properly prepared to function under the definition and framework of her role as specified in section 20-87a of the statutes and

2. the selected tasks and shared responsibilities of the lpn are continually changing as the art and science of nursing changes.

the board then made a number of conclusions including:

1. the lpn must perform her nursing functions and shared nursing responsibilities under the direction of an rn;

2. the lpn can contribute to the nursing assessment by collecting, reporting and recording objective and subjective data in an accurate and timely manner, that includes observation about the condition or change in the patient’s condition, and signs and symptoms of deviation from normal health;

3. the lpn can participate in the development of a strategy of care in consultation with other nursing personnel; and

4. participate in the assisting, delegating and giving of directed care

nurseprnRN, BSN, RN · Feb 27, 2012

for a lot of people, "scope of practice" means, "a laundry list of tasks it's ok for me to do." they think that somewhere in the sop there will be a sentence that says something like, "you must call your supervisor if the physician plan of care is dangerous by your assessment, and s/he must do thus and such, and call so and so..." not. this is not what a scope and standards of practice is.

what is not being learned about sop (and maybe because it's not being taught, but i wouldn't necessarily bet the farm on that) is what nursing is, as opposed to the tasks nursing does.

i would strongly recommend that anyone with the least bit of interest in this question-- and i devoutly hope that means everyone-- gets a copy of the ana scope and standards of practice with interpretive statements. it's a slim paperback and those interpretive statements could go a long way to clarifying these kinds of questions. available at your favorite online bookseller.

mazy · Feb 27, 2012

We had our scope of practice hammered into our heads in nursing school. However, I know that when I got out into my first job in an SNF, a true snake pit, we were expected to do things that we had learned we weren't supposed to do.

So I was often in a panic about it, knowing I wasn't supposed to do certain things, but then being expected to do them in my job. Also, since it was my first nursing job, I didn't know if that was something typical that I would encounter or if it was specific to the facility.

In other jobs since, the facilities I've worked for are very strict about scope, so now looking back I can see how corrupt the facility I worked in was.

**canoehead, BSN, RN** · Feb 28, 2012

What I've found confusing is that the Board's scope of practice does not line up clearly with what the hospital will allow you to do per policy. AND the hospital policy doesn't line up with what we are expected to do in real life. So, like Amanda T, we can refer to services, unless the doc doesn't want us to, or we must have a physician give a med, unless they tell us to go ahead. The IV drug admin policy written in the 90's says we cannot push X med, but the drug info handbook, bought by the hospital new every year says yes, pushing the drug is just fine.

Or the new policy that came out that changes everything, and no one has a copy of it. When that one person produces their copy it says in big bold letters "DRAFT," but we must follow the updated policy. No wonder we're confused.

sbostonRN · Feb 28, 2012

In my ASN RN program we took a short 2-credit class that was all about nursing ethics, legal issues, scope of practice and other issues like that. We were given a copy of the nurse practice act then. I admit I've never read it though I've skimmed through it. It's about 100 pages long and written in legal-speak.

MN-Nurse, ASN, RN · Feb 28, 2012

I hold licenses in multiple states, I read and understood the LPN and RN NPA before I even applied for a license. I've gone so far as to write the BoN when I didn't clearly understand something.

We covered scope of practice in class and in assigned reading very early on in nursing school.

The enthusiasm in the subject I saw in my classmates was, shall we say, less than exuberant.

wooh, BSN, RN · Feb 28, 2012

If it's against hospital policy, don't do it, even if allowed by your state's scope of practice.

If it's against your state's scope of practice, don't do it, even if allowed by your hospital's policy.

Hospital policy is going to be more exacting in do this, do that.

Scope of practice, you'll generally have to interpret a bit more. It's purposefully more vague, as it's impossible to list every task that has ever been and ever will be.

VickyRN, MSN, DNP, RN · Feb 28, 2012

It is taught in my nursing program and quite extensively.

dudette10, MSN, RN · Feb 28, 2012

i would strongly recommend that anyone with the least bit of interest in this question-- and i devoutly hope that means everyone-- gets a copy of the ana scope and standards of practice with interpretive statements. it's a slim paperback and those interpretive statements could go a long way to clarifying these kinds of questions. available at your favorite online bookseller.

i've read the entire thing, and i've even read the entire code of ethics for nurses with interpretive statements. nope, neither gets into specifics. they are very general and pie-in-the-sky.

in fact, this is what the ana has to say about an aprn's "scope of practice":

the american nurses association (ana) is often asked questions regarding the scope of practice of advanced practice registered nurses (aprns).
“is it within the scope of practice for a nurse practitioner to __________?”
“i’m an acute care np being asked to see pediatric patients – is that within my scope of practice?”
“do certified nurse-midwives see male patients?”
“do clinical nurse specialists have prescribing privileges?”
answers to questions like these are rarely simple. one must consider
scope and standards of practice
state law and regulation
institutional policies and procedures
self-determination
professional liability and risk management concerns
these web pages provide an essential foundation for understanding each of these areas, as well as links to additional resources.

bolding, italicizing, and enlargement are mine.

i guess i'm a little bit annoyed by some in this thread who imply the attitude of, "how can people who ask these questions be so dumb! don't they read their professional documents/state npas/policies and procedures?"

as one who is always reading about this stuff, i can tell you there are gray areas or outright contradictions in everything that leaves people with even more questions.

dudette10, MSN, RN · Feb 28, 2012

for a lot of people, "scope of practice" means, "a laundry list of tasks it's ok for me to do." they think that somewhere in the sop there will be a sentence that says something like, "you must call your supervisor if the physician plan of care is dangerous by your assessment, and s/he must do thus and such, and call so and so..." not. this is not what a scope and standards of practice is.

what is not being learned about sop (and maybe because it's not being taught, but i wouldn't necessarily bet the farm on that) is what nursing is, as opposed to the tasks nursing does.

i understand what you are saying in these two paragraphs, but the op listed very specific questions and then shook her virtual head in disbelief. some of my irritation is spilling over from what i have recently heard in my workplace about we nurses being too task-oriented, while we are given even more forms to fill out in triplicate for the simplest of interventions. and, if we don't fill them out, we get dinged. if you (the general you) want us to take our work to a higher level and not be task-oriented, don't make us do more tasks!

while it would be great to be able to exhibit all the qualities in the ana documents for every single patient, we are often swimming against the tide of bureaucracy, doctors who don't want to hear what we have to say, time constraints, staffing levels, and budgets/reimbursements. as a night nurse and a new nurse who doesn't have residents available 24/7, i struggle even more. i can pass all the recommendations i want to for patient care to the next shift, but if they are up to their eyeballs in carrying out the tasks with too many admissions, discharges to be done in x number of minutes after the order is written, orders coming in at lightening speed, and too many immediate medical needs that they need to address--all with not enough people--it will never change,

sorry about the rant. i fear it may be a bit off topic.

Perpetual Student · Feb 28, 2012

I'll give an example of a scope of practice issue that I wonder about: is it acceptable for a staff RN to push subanesthetic doses of ketamine for pain control purposes? Ketamine is typically classified as an anesthetic, and in some states therefore outside the scope of practice of the RN to administer outside of very specific circumstances. At lower doses it is an excellent analgesic, particularly for those who're extremely opiod tolerant. In many regards low doses of ketamine are less dangerous than the huge combined doses of opiods and benzodiazepines that the patient might otherwise receive.

In some states (Oregon is a fine example) the state BON has issued a position statement saying "sure, good to go." My state (Washington) has no such statement published, nor is there any clear way to derive whether it's acceptable or not. My take is that it is (or at least should be) acceptable, as giving low doses of ketamine for pain relief is fundamentally not dissimilar to giving opiods and benzodiazepines for the same purpose. Sure, if you give 50 mcg/kg of fentanyl you're anesthetizing the patient, but if you give 50 mcg every 3-5min and titrate it to pain relief, you're practicing pain management.

Unfortunately, many of my colleagues have interpretations that differ from mine (isn't that always the case? hehe). I'm reluctant to rock the boat. Fortunately, the anesthesiologists are usually still around and they don't mind administering the ketamine when appropriate. Our hospital policy has no statement one way or another, though I do believe this issue is currently being addressed in some of the pain management committees and such.

I had one patient recently who was having intractable pain despite multi-modal treatment with considerable opiods, a benzodiazepine, acetaminophen, and an NSAID. I called the anesthesiologist and she and I agreed that really the only option left for this particular patient was ketamine, but due to the grief I got the last time I pushed it, we decided not to go that route. Fortunately the anesthesiologist and OR crew were called in for another surgery and she was able to come and push some ketamine for me while getting ready for the next case. The patient's pain decreased from an 8 to a 4 within a few minutes and I was able to transfer the patient to the floor with her pain under control and her alert and oriented. Had the anesthesiologist not returned, I would've taken that poor patient to the floor with poorly controlled pain and sleepy as heck due to titrating the opiods and benzos to the edge of respiratory failure.