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Scope of practice question

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I work on a stepdown surgical unit that uses a 70/30 RN/LPN mix. We are trying to work out a policy of what gtts the LPNs can take (or can't and why not) and I'm looking to see what others are doing in their practice. We use a lot of Nipride and Esmolol and the LPNs don't take those patients, but there are some grey areas, such as PGE and titratable insulin drips. Does anyone have any policies and practices based on the following?

PGE

Insulin

Octreotide

Lasix

Dopamine (titrating vs. renal dose)

Fenoldopam (renal dose)

Thymoglobulin (not a drip, med w/ high adverse reaction rate).

To clarify further, our state code is vague and simply states that the LPN provides care under the supervision of the RN, MD, etc.

The hospital policy is just as vague as to LPN and RN scope of practice, so it's up to individual units to devise policies. Thanks in advance for everyone's help. MMB

gwenith, BSN, RN

Specializes in ICU.

I don't know your state but I have always held that ANY drug that is titratable requires the ability to evaluate patient response and evaluation is the highest of the cognitive functions. It is deemed much higher and harder to do than assessment.

I guess i would look to risk management to find out who is responsible if there was a med error with titration of a patient that an LPN was carrying for. Does this fall as 'under the direction of the RN' or is the LPN acting independently?

The RN in charge will also take responsiblity (legally and otherwise) if he/she delegates a patient to the LPN and there's an error that occurs, if it's determined that the LPN did not have the training/competency to handle the patient. The problem lies in that the staff have had training and competencies and ultimately, it's both the RN and LPN that will be held accountable. My unit is converting to a larger unit that will hold ICU beds as well (RNs will be carrying for those), but it's a confusing time.

Gwenith, I agree with you and I have brought up this issue with my NM which is why she wants me to research this and write it up. I know the legal implications of things given my law school background and my director of the unit was formerly in risk management. Essentially, I was told this is the way things are and that we have to work with it. My concerns are patient safety and preventing liability issues so any advice is welcome.

I would redelegate back to your NM....

gwenith, BSN, RN

Specializes in ICU.

You might be looking in the wrond place I wrote my answer form an education viewpoint - look for Bloom's taxonomy. It is a pyramid of cognitive levels. It is usually applied to writing of examination questions but can easily be used in a clinical setting for examination of competence.

It is difficult to see how an LPN who by definition is operating UNDER an RN's licence can be then expected to perform at the level of evaluation. - Please before I get flamed I am not saying that there are not LPN's who could not run rings around RN's in evaluation of the patient but legally this would not hold up.

Some websites

http://www.coun.uvic.ca/learn/program/hndouts/bloom.html

http://www.officeport.com/edu/blooms.htm

Hope this helps.

I'll try to clarify...LPNs are operating on their license and they must take competencies and continuing hosp. education to practice in a given area. That being said however, statutorily the RN or MD, etc. must supervise the LPN in their practice. That means delegating appropriate patients and changing assignments when patients become unstable, which is difficult to do at times. It becomes even more difficult if the LPN was deemed competent to perform a given task, then failed to accomplish it...she would be responsible, but the RN potentially gets pulled into it as well b/c she should have been supervising to ensure it was done, done correctly, etc. If I "redelegate" this to my NM, there is a concern that LPNs will suddenly be taking new gtts after taking "competencies" and I'm concerned that this may be a variance from the scope of practice from the national standards (or whatever standards I can glean from this board). Taking my bar exam next year is looking better all the time :). Thank you for the sites, I'll be reviewing them. MMB

This sounds like a very sticky situation, one that the management is taking an "do as we say" attutide on. Your LPN's should be trained on all of the gtts they will come into contact with and be able to recognize when a patient is in trouble but the ultimate responsibility will be with the RN. Some LPN's with more training have taken care of insulin gtts. They are able to read the orders, do hourly fingersticks and tirtrate the gtt, but they had to confer with the RN on each result and any change. Also Lasix. Maybe the key is getting some of the docs involved. They don't want their patients getting into trouble that can lead to a law suit, they could be approached with the idea of furthering the LPN's role with special training and what they feel is approiate gtt's for them to handle. They work with these LPN's too and they will be listened to quicker than the nurse. Sad but true. Good luck.

zambezi, BSN, RN

Specializes in CCU (Coronary Care); Clinical Research.

We don't even have any of those gtts on the floor except mabye the lasix. For the others, esp. nipride, corlopam, dopamine, even insulin, if they are being titrated, the patient is in icu/ccu...even renal doses or no titration they try to keep the patient in the unit...

I also think you should delegate this back at your nurse manager, who should bump it to the policy and procedure and pharmacy committees.

Someone should write a letter to the board of nursing in your state (LPN board and RN boards if they are separate) to ask them for clarification. Every state has different rules- I would want the board itself to clarify this.

The BON's decision in regards to questions such as these is to refer to institutional policy. It is quite different than other BON where there are clearly differentiated roles outlined and decisions are made on a case by case basis. My state's BON did adopt A Decision-Making Model for Determining RN/LPN Scope of Practice a few years back which is a flowchart, but I haven't found it to be particularly helpful. I have emailed the BON and awaiting a reply on a separate issue, so I may need to follow up with this as well.

Thank you everyone for your sugggestions- I will follow up with the pharmacy and policy/practice committee. Oh, what a sticky wicket! I'm going to sleep on it. MMB

Brownms46

Specializes in Everything except surgery. Has 27 years experience.

Originally posted by mmb-rnjd

I'll try to clarify...LPNs are operating on their license and they must take competencies and continuing hosp. education to practice in a given area. That being said however, statutorily the RN or MD, etc. must supervise the LPN in their practice. That means delegating appropriate patients and changing assignments when patients become unstable, which is difficult to do at times. It becomes even more difficult if the LPN was deemed competent to perform a given task, then failed to accomplish it...she would be responsible, but the RN potentially gets pulled into it as well b/c she should have been supervising to ensure it was done, done correctly, etc. If I "redelegate" this to my NM, there is a concern that LPNs will suddenly be taking new gtts after taking "competencies" and I'm concerned that this may be a variance from the scope of practice from the national standards (or whatever standards I can glean from this board). Taking my bar exam next year is looking better all the time :). Thank you for the sites, I'll be reviewing them. MMB

First Thank You for a well written, and well thoughtout presentation, on your unit's dilemma with this situation. I can understand your concern, and the frustration you're feeling. I agree that it might be a good idea to bring in the MDs in on this. I also think that maybe the policy could be worded to hold each LPN who takes and succeeds at passing the competencies, acountable for the performance of the skills they have supposedly acquired.

I have read Nurse Practice Acts, which state, that the LPN is responsible for the skills they have acquired, and have documented compentencies. and will be held accountable for the preformance of said skills. To me it would seem to be the same as holding them accountable for any med, and or care they would give.

But then again, you're correct in saying the RN could be called into account, for not properly supervising the LPN for the care she has delegated. This is really a no win situation in many respects. Plus you must worry about the one time an LPN who normally preforms well, makes a mistake, or just is careless in the preformance of the skills delegated.

What I'm wondering is, have you contacted your board of nursing for guidance on this problem??? I think that is where I would go, as they have the resources, and the ability to give the best information, and or direction on the development of such policies. I mean isn't that one of their functions???

How do the LPNs feel about taking on these new requirements being added to them????

The majourity of the LPN's are new to nursing and are dealing with adjusting to caring for stable patients...they still need experience and education to move away from simply "performing tasks" to understanding why they do what they do and be able to analyse the whole situation. This is not limited to the LPNs however, as we have a small senior staff and a great deal of new grads, mainly RNs with the same issues. I am awaiting a response from the BON...but as I've said previously, I don't hold out much hope since this particular state dislikes regulations and the BON in the past shifts the issues to the institution. MMB

Brownms46

Specializes in Everything except surgery. Has 27 years experience.

I'm sorry MMB, I must have missed your posting on how unhelpful your BON was, as it seems we were both posting at the same time. I sincerely hope you find a solution to your problem, that will give your patients, and your new staff the best outcome.

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