Scope of Practice question

wooh, BSN, RN · Mar 26, 2012

Fast forward to first nursing job. "They're bullying me by answering my questions!!!"

wish_me_luck, BSN, RN · Mar 26, 2012

wooh, I was referring to "mindlor" as the one who needs to chill out. That person was hateful. Also, it seems like after the first couple of answers of P and P manual, I think I am good. If you have nothing meaningful to add, wooh, just don't answer at all. PS: if anyone knows how to delete this thread, please do it or tell me how. I have no problems with opinions, but when it goes on and on without any meaningful discussion, then it needs to be done. Thank you in advance.

imintrouble, BSN, RN · Mar 26, 2012

:icon_roll Uh oh.

SHGR, MSN, RN, CNS · Mar 26, 2012

Is giving advice on what to do in a situation within the scope of practice? I tried to look at my state's website and it gives a decision tree without any real clear answer. I have taken a leadership class, but I guess I go through certain situations in my mind and think of what you would do. Okay, if someone calls and says they are having an allergic reaction...I would probably ask for them to describe the reaction (airway involvement versus a rash or something), if airway, then go to ER/call 911. Then, they would probably gather rest of info in ER. But, other reaction, I would want to know, the circumstances around it (were they outside playing in poison ivy, did they take a medication, were they eating something); has this ever happened before; timing around it; what medications/food allergies do they have; etc. If it is a skin reaction or to the like, would it be okay to tell them to put hydrocortisone cream, cool compresses, and/or if they are not allergic to benadryl (OTC), to take it? Or is stuff like that not within the scope of practice?
I have times where I am frustrated because I know what can be/or most likely will be/protocol for treating something, but most things cannot be implemented without a doctor's order. The scenario I am thinking of above would be like an out patient clinic as opposed to hospital/LTC.

You may want to purchase a copy of Briggs' Telephone Triage Protocols for Nurses. That is the book we use as P&P for, you guessed it, telephone triage. It's a great resource. It covers all the basics and more and it sounds like it will answer some of your questions. The situations you are describing are well-covered within its pages.

I agree, threads here sometimes go off-topic. There are some members here whose advice I value, and some I don't...take the good, let your skin thicken, but never lose your compassion.

Esme12, ASN, BSN, RN · Mar 26, 2012

gallatea, I appreciate your post so much. You are one of the few that acknowledges that it gets confusing, but explains how much more intense an MD program is. I am frustrated somewhat because what originally my post was about was how you would handle situations like that...and the reason I asked was because I didn't know at what point as a future nurse, the scope of practice would end. But, some how it got into MDs know more, etc. Then, "i'm in trouble" just told me "You are scary", etc.
Plus, I did go looking for the scope of practice within the state I want to practice in and could not find a clear answer. I did not use "all nurses" as a first step. I do have ANA scope of practice, but from what I understand, state scopes are more specific and P and P manuals at facilities have even more bearing.
I got irritated because we are taught so much about illnesses (and at my school, we are tested to the bone--med calculations test, courses tests, standardized testing after each course that we have to pass or we fail the course, then medcalc tests again (beginning of each semester), and we have a comprehensive test we have to pass. Plus, clinicals that we have to do full head to toe assessments...no focused assessments unless in practicum (which is only because preceptor may not have that time) and our CPE are now 8 pages long. They are so specific. I will say this, I feel like I may have had a better clinical experience than apparently some people on this forum. I am at the end and I have done 20 IM inj (yes, I am keeping a count because from where I am younger, people look at me like I am not old enough to be doing that or since I am a student, I am an idiot), I have spiked quite a few IV bags and programmed pumps, I have done enough Accuchecks and insulin admin. to last a lifetime (yet, still have a second person check the insulin before admin to make sure...we were told to always have a second person check blood and insulin), I have started IVs, done venipuncture, put in foleys and in and out, taken out drains, changed dressings, given medications PO/IV/IV push, etc.
Okay, I am done with my rant. I am not a know it all and I will be the first to admit when I am wrong or don't know something, but Heaven forbid I cut myself some slack and say I am not completely dumb; then, I get jumped all over.

I have read the whole post and I hear what you are saying, but this is a public forum and people are entitled to their own opinions and have the freedom to edit their posts. I don't think you were being attacked but rather hearing a reaction to what you said and how you said it.

I think that as you mature in the profession you will see how all your schooling ties into the practice of nursing. YOur are responsible for your patients in the absence of the MD and need to understanding the whys and how's disease process occur to respond early to emergent situations that will arise in your daily practice. It is because we know better that we can do better.

No one was calling you "dumb" but they were trying to answer the dilemma that you are struggling with. It takes more than a few IM injections, spiking a few IV bags, and a few Foley's to be considered experienced enough to give "advice". The accuchecks and insulin you have performed will pale in comparison to what lies ahead. Everyday we as nurses make independent decisions as to whether to carry out the MD order or administer that medication. We are independently responsible for our actions if we carry out an order that was not appropriate or dangerous because the MD isn't always right and the patient is our responsibility to protect. The buck stops with us.

Giving advice is a very dangerous thing to do, even when following policy and procedure. If it sounds like someone is having heartburn after eating 15 jalapeno poppers doesn't mean they aren't having a heart attack. If you tell them everything is fine and to take pepto-bismol and they have a heart attack....you can be held liable, and sued for delay in treatment as well as having your license revoked.

In the Emergency room setting people call ALL the time asking for diagnosis over the phone. We give none other than 1) Hang up immediately and call 911 2) Call your PCP or put Ice on it but make sure the ice is not in contact with your skin and call your PCP and 3) It is impossible to tell you what is wrong over the phone, we don't know you or your history...you are Welcome to come to the ED and be seen or you can call your PCP.

You are dealing with the general public and you cannot idiot proof your responses. Many people do not use common sense and cannot be trusted with the accuracy of their stories. While I may know absolutely know what is wrong with them on the phone I do not want the responsibility of getting it wrong. The triage area is an area that (in most facilities) only the most experienced RN's occupy due to the importance of "getting it right" as to what the issue is and who needs to go first.

That parent that come to the ED with their first born that has a chin laceration do not believe you that the child is fine and can wait for the stitches......the child will survive this injury and their life is not in danger by waiting. I once had a phone call from an airplane ie: that a passenger (they were a member of the hospital had code for they had a medical record number)" and wanted the flight diverted because his wife had a dilated pupil.

It was through experience and knowledge and knowing what questions to ask (due to pathophys of disease and pharmacology) that I asked if anyone in their party had a scopolamine patch on for motion sickness because I knew that if you touched the patch and touched your eye it will dilate the pupil. I told the gentleman on the phone that I could not give advice on the phone but the most likely cause of the pupil dilation was that his wife out his on and touched the med which got on her fingers AND I had no authority to divert any aircraft as that was the captains/flight attendants job, they are trained for emergencies and (hopefully) know their jobs. Who knows what happened from there but I Was covered (hopefully) from any liability by making it clear what I could/would and could/would not do.

IN a clinic setting even though you know what to say you are limited to what "advice" to give by policy and procedure on the physician's orders and permission. But trust me when things go awry your "trusted"MD will turn on you in a heartbeat and toss you butt under the bus so quick your head will spin. So you need to be very careful in what you say and how you say it.

Telephone triage is a new trend amongst insurance companies and some private practice. You ask question from a computer program with scripted responses (mostly) and it will always end with......If you don't feel better or if you feel worse/changed go to the emergency room and call back or call your PCP. But it is prescription for liability reasons. It is through knowledge and experience that you get a "feeling" that something may be amiss and advise them to go to the ED. Again proving that the knowledge of disease process and the pathophysiology will be necessary to perform your job safely and accurately.

There are different areas in medicine that allow for more independent thinking and action like OB/L&D, NICU, PICU, Cath Lab...... Critical Care areas and Emergency medicine ( that can lead to trauma flight) and you may find that you will gravitate to one of these areas, but only after a couple of years experience, or an intensive residency/orientation.

I have carried malpractice insurance for 33 years, technically even longer, as I carried it in school. I carried it not because I thought I wasn't safe, but because I knew I was human and I know e live in a litigious society. I did not introduce myself to my patients "Hi my name is Esme and I carry malpractice insurance, so I'm safe and if I screw up you can sue me" I carried it to protect myself, my family and everything I had ever worked for.....to keep it safe.

Sometimes nurses get themselves in hot water by over confidence in their abilities that they over step their boundaries. Sometimes nurses get in trouble because the forget where they are and the limitations on what they can do in specific area. Example: as a Trauma flight nurse I was also a paramedic. As a paramedic in the field I could intubate and a nurse in the hospital I could not unless specifically allowed to by policy. Some nurses feel they know more that they do and become over confident which will also land them in hot water.

Your License is in danger at all time but it isn't as precarious an it is made out to be. But nurses get disciplined everyday for innocent mistakes that will change their lives.....regardless how long they have been a nurse. Your insurance will provide an attorney. Phone advice IS a grey area and any nurse involved needs to proceed with caution.

Humility, knowledge, dedication and caution are key to a successful career.

I wish you the best, Good Luck!

AnonRNC · Mar 26, 2012

I HAVE read this whole thread and I have a comment that I feel is valuable.

I work in the NICU. NICU is a very narrow field; there are limited number of things that can go wrong with a baby. I know those things pretty well. Last week, a weird thing came up. My patient developed a symptom that I knew was outside the bounds of "normal," but also didn't fit the usual NICU "recipe" for problems. Upon reporting that symptom to the physician, I saw this typically lazy/casual doctor LEAP into action: x-rays, blood work, surgical consults, phone calls to parents - the whole works.

As I drove home, I contemplated what had occurred. And came to realize that while I know most of NICU and can predict the medical diagnosis and prescribed treatment 95+% of the time...THE PHYSICIAN KNOWS MORE THAN ME. He/she has a broader understanding of the nuances of the matter. And I have a much broader understanding of the nuances than a nurse with half my experience. I have been a nurse for more than a decade and just last week came to this realization.

It will come to YOU in time.

Until then, continue to ASK QUESTIONS! Getting questions answered by reliable sources increases your knowledge - never stop asking questions.

Home Health Columnist / Guide · Mar 26, 2012

Closing thread per OP request.

Just a general reminder to members: when one posts on the internet you will often get advice both pro and con over ideas posted. I caution all to be prepared to handle negative reaction/difference of opnion; otherwise consider not posting if unable to tolerate counter opinion. Sometimes we learn best from situations when we reflect on merits of opposite postitions and grow from the experience.

DixieRedHead, ASN, RN · Mar 26, 2012

Within your scope of practice, in any state, anywhere: " If you feel you are having an allergic reaction, please call 911."