Scope of Practice question

Double-Helix, BSN, RN · Mar 25, 2012

What do you mean if the person "calls"? Are you talking about a friend calling their other friend who is a nurse for advice? Or a patient calling a doctor's office for advice? Or a patient calling a nurse-information line?

The answer is that there are usually protocols in place for this at facilities. Doctor's offices usually ask that the nurse collect information from the patient, then inform the doctor of the complaint, and the doctor will make a recommendation that the nurse will call the patient back with the doctor's response.

There are also phone-triage centers where the patient calls the nurse on the line for advice. I'm not familiar with the regulations of such businesses, but I would assume that it works the same way- there is a doctor available to the nurses to consult if needed.

As far as a friend calling you, an RN, for advice, you've got to use your best judgement in answering. Yes, you could be held liable to a higher standard for giving advice, because you are a nurse. The best response in these situations is to encourage the friend to call their primary doctor.

It is not within the nurse's scope of practice to diagnose illnesses and prescribe treatments, either over the phone or in person. You you cannot listen to a patient recount their symptoms and say, "That's a skin reaction, so put hydrocortisone cream on it." Because in that situation you have diagnoses the problem and prescribed a treatment.

kids · Mar 25, 2012

Call centers/clinics/phone advice/etc that use published protocols very often include standing orders in them.

The clinic advice lines and call centers I've worked had protocols/decision trees for allergic reaction, fever, pink eye and thrush (they actually had hundreds of protocols, I just grabbed some easy ones from memory).

The call comes in and you gather patient identifiers (for the record) and background info on what prompted the call, that drives which protocol(s) you pull. The background info also determines if the call is even appropriate for the application of protocols.

The protocol leads you to ask specifics about what is happening (and also has you asking questions that may trigger another protocol- fever with a rash is an example). The decision tree within a protocol works down in accuity; first you rule out if this is ER worthy, then urgent office visit, then treat at home.

If home treatment is appropriate, the protocol gives the home care instructions including calculating dosages of OTCs and instructions on their use. The protocol may also include standing orders to call in a prescription for 'simple' Rx meds: Nystatin for thrush, abx drops for pink eye.

Some clinics may also use established protocols in clinic for things like strep.

The thing I can't stress enough is NEVER give advice without using a practice approved, physician signed protocol and that you document exactly what protocol you used. One clinic I worked for did it all on paper and you made notes right on a copy of the protocol, at the call center I worked for it was all computerized and you clicked through boxes (so there was minimal documentation).

I agree, telephone advice using established protocols is in effect diagnosing and prescribing treatment but it is a system of delivery that is approved of by the BoN in many, many states. And think about it, any time a nurse implements a standing order s/he is in effect diagnosing or treating a problem.

The American Association for Office Nurses and the American Association of Ambulatory Care Nurses have developed standards of practice for telehealth nurses (which telephone advice/triage falls under).

mindlor · Mar 25, 2012

In general, I feel that if a person is well enough to get on the phone and call a nurse for advice it is most likely not an emergent situation. That said, the best afvice the nurse can give is that they should contact their HCP, explaining that nurses are not allowed to give medical advice.

Why even take on the liability and risk losing a license?

mindlor · Mar 25, 2012

Personally. I dont want my friends and family calling me for advice, especially when I know they will just do the opposite of what I suggest or spend hours trying to tell me why my thought process is wrong lol.

kids · Mar 25, 2012

I want to re-state: NEVER give advice without using a practice approved, physician signed protocol and that you document

exactly what protocol you used.

NCSBN: Position Paper on Telenursing: A Challenge to Regulation https://www.ncsbn.org/TelenursingPaper.pdf

ANA: Legal Considerations for Nurses Practicing in a Telehealth Setting Legal Considerations for Nurses Practicing in a Telehealth Setting

wish_me_luck, BSN, RN · Mar 25, 2012

okay, chill, people. I asked because I didn't know. So, basically, it's per facility protocol. I am a nursing student (getting ready to graduate), I get confused sometimes on what we can do because 1) I was taught health assessment from an NP book, 2) I honest to God (no offense) think nurses probably know as much as a physician to the point where I just want to help the patient as quickly as possible. Unless it's an unusual situation, you already have an idea of what the physician will do and I have times where I am frustrated not because I don't know what to do, but because I do but can't. 3) when I looked at the scope of practice in the state I am looking at working in, I could not find anything real clear as to what was within the scope for the state and what was not.

But, okay, got it. Protocol will tell what to do (most likely info. gathering) and give info. to physician for evaluation. Does this not frustrate you all sometimes though? I feel at times that nurses have a very limited scope of practice, yet have a high responsibility and accountability.

mindlor · Mar 25, 2012

okay, chill, people. I asked because I didn't know. So, basically, it's per facility protocol. I am a nursing student (getting ready to graduate), I get confused sometimes on what we can do because 1) I was taught health assessment from an NP book, 2) I honest to God (no offense) think nurses probably know as much as a physician to the point where I just want to help the patient as quickly as possible. Unless it's an unusual situation, you already have an idea of what the physician will do and I have times where I am frustrated not because I don't know what to do, but because I do but can't. 3) when I looked at the scope of practice in the state I am looking at working in, I could not find anything real clear as to what was within the scope for the state and what was not.
But, okay, got it. Protocol will tell what to do (most likely info. gathering) and give info. to physician for evaluation. Does this not frustrate you all sometimes though? I feel at times that nurses have a very limited scope of practice, yet have a high responsibility and accountability.

To think that nurses know as much as doctors, NP's or PA's is a huge mistake. The best policy is to give absolutely no medical advice unless of course you work as a telephone triage nurse operating under strict protocols...but most nurses are not practicing in this capacity.....

I am also a soon to be new grad. Many of us think we are all that and a box of chocolate. its a mistake. Our learning is just about to begin......

Sun0408, ASN, RN · Mar 25, 2012

Your number 2 reason really scares me. You are still a nursing student and trust me, you really don't know jack. Medicine is very complex and that is why MD's go to school a whole lot longer than we do. If you feel the profession you chose is too limiting, go to medical school.

wish_me_luck, BSN, RN · Mar 25, 2012

what I am referring to is when we learn stuff from the book/in class (can't speak for you), but we have to know what the illness is, the patho, the signs and symptoms, treatment, complications, plus your most likely nursing diagnoses and goals for the patient. Plus, when we did assessments, we could not listen through gowns and we had to do full assessments (LOC, pupil checks, jugular distention, heart/breath sounds, abdominal inspection, auscultation and palpation (we learned how to deep palpate/percuss, but did not normally do that), ROM/strength of extremities, check for edema, capillary refill, and of course your other checks such as IV site, output of cath. if applicable, etc. Also, vitals. When we were in the class portion, our final assessment for passing was that we drew from a bowl which focused assessment we were going to do. My partner I think got cranial nerves check, and I got checking eye sight with Snellen chart and something else. My point is, what we learn to do as far as assessment and such, our assessments are as thorough sometimes as what a physician would do. Oh, and another classmate had the Weber and Rinne tests for hearing.

That is why I sometimes get confused, because we learn to do much more than what technically we can do. I am not being a know it all. So, do not be hateful. Thanks.

wish_me_luck, BSN, RN · Mar 25, 2012

I am not trying to turn this into an argument. All I am saying is I wish nursing schools would not inundate us with info that technically under our scope, we can't do. It gets confusing.

Another thing I get confused on is we are told "you would be considered negligent, if you didn't tell the patient ______ (fill in the blank), if they are on ______." But, yet we can't tell them certain other things (such as mentioned above). I guess sometimes I think "shouldn't the physician be telling the patient they can't have this food or that food; or that they can't take this herb/drug with that drug; etc.?" I don't know where it crosses the line sometimes and when I try and look, I can't find a clear answer.

mindlor · Mar 25, 2012

How many hours of clinicals have you done? How many full assessments have you observed in the hospital setting?

How much time do docs spend assessing patients. The reality is that you have 5 , 10 minutes tops to assess your patient. Focused assessments rule the day. You can assess a lot by popping in and saying hello and getting an appropriate response.

Have you done your preceptorship yet?

Come back and let us know how that goes when you have 6-8 patients to assess, pass meds to, etc, etc.........

Anyway, I know your personality type, and based on that assessment I will spend no more time here.....

I wish you well.