Outside Scope of Practice in CA?

[CalsMom]

I've been an RN for 10 months and after 4 months of working on a neuro step down unit, I've been asked to cover for the RN in the neurosurgery dept while she is out on maternity leave. I was told by the manager of that clinic that the RN is expected see pts on their 1st post-op visit to remove staples, sutures, etc. Also, the RN performs the pre-op history and physical. However, the RN does not sign this pre-op form but completes it and then leaves the signature line blank for the MD to fill in later. Furthermore, the clinic RN rounds on the patients in the hospital and writes DC orders and pulls the JP drains. The nurses on the floor call the clinic RN if they need new orders. One of the RNs in the clinic will write med orders without checking with the MD because she says she "knows he would agree with this."

My head is spinning because I see so many red-flags with this job description. It seems like this job is more for a clinical nurse specialist or NP? I perused the Nurse Practice Act for more clarification but can't find anything specific to the above. I guess I'm concerned for patient safety if the clinic RN is expected to perform as an independent practitioner in some aspects. I'm looking for any insight or advice before I speak with the manager about my concerns. Maybe I'm just feeling a little overwhelmed because I'm still a new grad. Any thoughts?

[suzanne4, RN]

They are definitely overstepping their RN license and could face charges.

They do not have the training to be doing the H and P and then just having the physician sign off on this.

And they should not be writing orders because they know that is what the physician would want.

And the thought that they want a new nurse to do this is even scarier. Suggest that you speak to the manager about this, the job description is not one the RN Scope of Practice in any state that I am aware of. And as an RN, they are practicing under their license, and not under the license of the MD.

Your Risk Management also needs to be aware of this.

And you are quite smart to question what they want you to do. It is one thing if the nurse pulls sutures in the office, or even staples; but to do it in the hospital setting and without an actual physician seeing the patient, then that is non-acceptable behavior. What they do in an office setting does not extend into the hospital approved list of practices.

[suzanne4, RN]

Writing orders is not under the scope of practice of the RN either.

Taking a verbal order is another thing and not the same as this if others are questioning this.

[gonzo1, ASN, RN]

It is possible that they are trying to give this job to a new RN because they can't get an experienced one to take it because of all the red flags.

I work in TX, IL and AZ and a lot of what you are talking about is out of the scope of practice for these states.

I wouldn't want to work for an MD that would sign something someone else filled out.

What other kinds of corners is he cutting

[ebear, BSN, RN]

Make sure this job description is in writing, then fax a copy to your state's board of nursing for review. All of these issues are outside the scope of practice for RNs, except suture or staple removal AFTER THE PHYSICIAN SEES THE PATIENT. I guarantee you this policy will change. DO NOT take this position under these circumstances. To do so will jeopardize your license.

[CalsMom]

Thanks everyone for their words of wisdom. I met with my supervisor and relayed my concerns. It appears that I was not the first RN to raise questions about the practices in the neurosurgery clinic. My manager met w/ corporate compliance and they revised the policies. They also met with the surgeons and re-educated them on the RNs role in the clinic.

I've been working there for a few weeks now without any problems until yesterday....

I had a pt come into the clinic that had a dorsal column stimulator placed about 6 weeks ago. Her sutures had already been removed but she was complaining that one of the incisions felt "hot" and thought it was the generator "overheating." Her temp was 100.1 and the incision was was flaming red and indurated. The incision had opened up and there was a layer of stringy,yellow eschar in the wound. I was very concerned that she had a wound infection and it looked like the wound needed to be debrided and she needed to be started on ABX. Of course, the pt's surgeon was out of the office that day and so I told the PA-C my concerns. Well, she flipped out on me! Every other word out of her mouth was the "F" word. I was told that she didn't have time to deal with this wound and I would have to take care of it on my own. I told her that RNs can't debride without an order and I most definitely was not trained to do sharp debridement...plus I would need an order to give ABX. I insisted that she see the pt. After her tantrum she did assess the wound and agreed that it would have to be surgically debrided and re-sutured.

I mentioned this incident to the other nurse and she told me that the docs already think I'm a "troublemaker" b/c I brought up the whole scope of practice issue and she advised I just keep it to myself since the patient rec'd the care she needed.

This assignment has become so stressful...I guess I'm just looking for reassurance that I did the right thing. I hope I can make it six more weeks without losing my mind.

Thanks for listening.

[mdfog10]

You did the right thing. I believe that Physicians (especially in a clinic setting), get upset when you cause "trouble" because they want you to just do it and make their lives easier. They don't care about scope of practice and they think you , in CA, cost too much. So not only do you want the best for the patients , but you also need to protect your license. I hope you are covered by a union. It is also difficult in a clinic setting because you may be the only nurse , and are up against the doctors and practice managers (who have no medical license).

take care,

mdfog10:banghead:

[traumaRUs, MSN, APRN]

In my opinion, you need to get out of there. What they are asking for is outside your scope of practice. Doubt they will cover you when they get a complaint or suit.