Scope of practice in the OR, am I the only one that sees a problem with this?

[jamiebell, RN]

I have been an RN in the OR for 16yrs. I was a surgical tech for 6 years while putting myself through nursing school.  As a scrub tech at a teaching hospital, your scope of practice was cut and dry.  I am now currently in school for my RNFA. About a year ago, I got married and moved. I now work at a much smaller hospital. 90% of the staff (CST & RN) have ONLY worked in that operating room. I find myself struggling with the CST/STs that practice outside of their scope. (Suturing, making incision, putting in ports, stapling across bowel) Just to mention a few things. I have spoken to the OR manager about the scope of practice for a CST/ST. I get no answers from them as to why the scrub techs are practicing as a first assist without proper training or credentialing. I have informed the manager these behaviors are still happening. The response I have gotten, “Under direct supervision of the surgeon“. Do the surgeons know that the scrubs are not qualified to execute these tasks? Or have they just done whatever they had to, to get through the surgeries? None of the CST/ST have first assist training. I know there is legal liability when staff are working out of there scope of practice. I have been there over a year and nothing has changed! The other RNs say you have to pick your battles and nothing is going to change because of poor management. Any suggestions???

[Rose_Queen, BSN, MSN, RN]

It really boils down to training. Unlike the RN, the ST in most states will not have a legally defined scope of practice. We do allow our STs to suture provided they complete our established process, which includes classroom time and simulation practice followed by provider supervision a set number of times. Once they have completed that and been deemed competent by the provider, they may suture independently. However, we do restrict any incision, trocar placement, and bowel stapling to first assistants. We have had travelers come through who have been trained to harvest vein for bypasses (we don’t allow a non- PA/NP/ surgeon to do it, but it’s not unheard of)

[Wedgepressure, ADN, EMT-B]

Honestly,  it sounds like your making mountains out of mole hills.  Inquiring about the CSTs scope isn't really in the purview of your scope.  To me this really doesn't affect you or your license in any way and it's not even something that needs to be addressed by you. 

[klone, MSN, RN]

I disagree with the previous poster. This comes down to patient safety, and that's everyone's concern. Also, if you were aware that CSTs were working outside their purview of training, and there is a bad outcome, you could certainly be named in a lawsuit, and they would ask "If you knew the CST didn't have the proper training, why didn't you speak up?"

What it comes down to, when TJC comes to that hospital, they're going to ask "Show me the documentation indicating that the CSTs have received the proper training and are competent to do these procedures." And if your facility doesn't have that documentation, then they'll be SOL.

[jamiebell, RN]

I ?% agree. I have informed my manager that the CSTs are acting as first assist/RNFA/PA/NP with out the proper education and this is a legal liability. I do not work with certain scrub techs because they know I have spoken up about this issue. Management has done nothing to my knowledge besides me not working with those scrubs. Other RNs and staff have said, nothing will change and all you’re going to do is make it harder on yourself by pushing the issue.

[Wedgepressure, ADN, EMT-B]

15 hours ago, klone said:

I disagree with the previous poster. This comes down to patient safety, and that's everyone's concern. Also, if you were aware that CSTs were working outside their purview of training, and there is a bad outcome, you could certainly be named in a lawsuit, and they would ask "If you knew the CST didn't have the proper training, why didn't you speak up?"

What it comes down to, when TJC comes to that hospital, they're going to ask "Show me the documentation indicating that the CSTs have received the proper training and are competent to do these procedures." And if your facility doesn't have that documentation, then they'll be SOL.

The CSTs proof of competency and training has nothing to do with a circulating RNs role or responsibilities. If there was a bad outcome, and you were brought in for a depo regarding a CST doing specific procedures outside of their scope all you would have to say is that it is not within my purview as a circulating nurse to know the CSTs scope of practice.  Also if the MD signs off on it, it's as if the MD DID it in the documentation.  The documentation will reflect that he did it. He will have to answer.  The circulator is not responsible in any way.

This truly is a non issue, and for the nurse to speak up about this and call out the entire CST staff can hinder the nurses ability to function optimally within the team dynamic. 

These actions can actually have the reverse affect on the circulating nurse. It can paint that nurse out to be untrustworthy by other staff and often times that nurses practice will begin to be scrutinized and they are at hirer risk for being reprimanded for things that otherwise would not be an issue had they not spoken up about other staff.

By being too nosy in other peoples business you can actually make your personal and professional life much more difficult than it needs to be. 

[FolksBtrippin, BSN, RN]

First off let me tell you that I have never worked in the OR and I know very little about circulating.

But I'm chiming in because I have run into the problem of witnessing techs acting outside of their scope and me consequently fretting about my responsibility to correct that problem.

And I have definitely noticed the problem that wedgepressure points out-- the problem of losing trust from the team, and consequently having people put your practice under a microscope because you have called out the culture.

For this reason, I think you need to be judicious. You should report unsafe practice  because your primary responsibility is to your patient. But is that what you are seeing? Like... are you seeing CST/STs doing something unsafe for your patient? Or are you just concerned that they are acting outside their scope? Because the former is important enough to speak up and the latter makes you kind of a tattletale unnecessarily.

Again... I don't work in the OR and I don't know how bad it is that these folks are suturing, etc. I just know how bad it is for you if you can't be a team player because you keep blowing the whistle on stuff that isn't really foul.

 

[JBMmom, MSN, NP]

12 minutes ago, FolksBtrippin said:

I just know how bad it is for you if you can't be a team player because you keep blowing the whistle on stuff that isn't really foul.

You've gotten some good feedback. If you feel like these things you've seen are endangering patients then it's worth pursuing. Since you don't necessarily know the training of the people that have been working there, you could be calling someone out that they don't feel are working outside of their scope.

The nearest example I have is that in my state, nurses cannot push propofol. When we're intubating a patient, sometimes the CRNA will hand us the propofol syringe and ask us to administer. I've clarified with one of them that their interpretation is that because the CRNA is standing at the bedside when the nurse pushes it, we're okay. I suppose if I were totally concerned about my license I would have rights to refuse, but it's usually because they can't physically reach the IV site while intubating. It's possible that these techs have been taught by the surgeons and first assistants and as long as they are readily available, it's an okay practice, if not the preferred practice. Worth blowing a whistle and potentially disrupting your working relationships? Only you would be able to answer that.  

[Nunya, BSN]

I'm not sure your license would be at risk if they did something wrong, but then I'm not sure it wouldn't.  Maybe call your BON and see if they have an answer? Just don't give your name or location, and use a non-medical person's phone ?

[rn&run]

I've only worked in one OR, but what you're describing @jamiebell is concerning to me. 

From the Association of Surgical Technologists:  "Wound closure is performed under the broad delegatory authority of the physician, as defined by the American College of Surgeons, the provisions for which vary from state to state and according to state law and health care facility policy. Therefore, it is the position of AST that only the individual who has attained the credential of CSFA has the knowledge, training and experience to perform advanced task functions in the closure of body planes.

Moreover, the Association stands against a single person holding the dual role of scrub tech and surgical assist.  They claim that "when the CST is utilized in a dual role, effective case management, organization of thoughts and activities critical to safe and efficient patient care, awareness of aseptic technique by all surgical team members, and quality of surgical patient outcomes may be compromised.

Long story short: if the scrub tech is busy suturing/incising/etc, he/she is effectively unavailable to function in their capacity as scrub tech. 

Full AST position statements available here: https://www.ast.org/AboutUs/Position_Statements_Guidelines/

Disclaimer #1: In my brief review, the Association of Surgical Technologists appears reputable and evidenced-based, but I am not a member, nor am I a surgical tech. 

Disclaimer #2: Workplaces do not necessarily adhere to what is right, or evidence-based. Advocating for EBP against unit culture may get you ostracized, retaliated against, or fired.  

[Nurse Pompom]

On 4/5/2021 at 4:42 PM, Wedgepressure said:

Honestly,  it sounds like your making mountains out of mole hills.  Inquiring about the CSTs scope isn't really in the purview of your scope.  To me this really doesn't affect you or your license in any way and it's not even something that needs to be addressed by you. 

That..

They are supervised by surgeons.. you're not the tech police.. they aren't doing anything on their own.. you raised your concerns, now let it go..

[OR_RN]

I'm not sure what state you're practicing in, but this would be of concern to me as a circulating RN. The scrub tech works under the RN license in my state. If something were to happen it would be the RN license on the line for the scrub tech working out of their scope, not the MD. I would check with the board of registered nursing in your state and determine whose license they are working under - the RN or the MD?