Scope of Practice question

[wish_me_luck]

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.

[Sun0408, ASN, RN]

Yes, it can be very confusing and you will learn as you go. The more we know, the better able we are to protect and advocate for our pts... We have to know S&S, this allows us to keep an eye out for this or than and report our findings back to the MD. Our assessment skills as well as knowledge on what tests, tx, meds would be appropriate for our pt is needed, why; because MD's are human too and yes they make mistakes and we are there to look out for the pts. Say your pt is tanking and the MD orders the wrong drug, it is you that should know that med is not appropriate and question the MD. If you didn't have that education, you would just follow orders and harm your pt. I have had MD's in the middle of something or half asleep give me orders for levo when the pts BP is already sky high, um doc wrong med.. The more you know, the better off your pts will be.

[wish_me_luck, BSN, RN]

mindlor, you said you were in nursing school as well. I am getting ready to graduate, so yes, I am one week from finishing preceptorship. I have had 4 semesters of med-surg, including preceptorship (I did a med-surg preceptorship). I had to do full assessments on patients in the first 3 semesters because I had to fill out a packet with a full assessment in it and document assessment in the health system charting. Preceptorship, I do focused assessments and hate them. I do it that way because that's what my preceptor does; but I keep my mouth shut and just think when I am by myself, I can do a full or focused. I actually used to tech on a floor where a nurse did do full assessments and she was a wonderful nurse (she was even charge nurse).

I am not attacking you. Plus, this whole discussion was a scope of practice question, not about getting you to go on the defense. Thanks.

[wish_me_luck, BSN, RN]

Thank you, Sun! See that is the type of answer I am looking for. It explains that apparently 'yes, we have an idea of what a doctor knows, but for a different reason'. It helps a lot. I did not post to make people P.O.ed.

[nurseprnRN, BSN, RN]

op, the reactions you're getting are less a matter of scope (as you know, doing those tests are within scope of nursing practice, although for some aspects the results do not allow nursing interventions, and some require np licensure) and more a matter of alarm over your inexperience. giving phone recommendations is only a matter of institutional policy if the position is specifically for that purpose, i.e., a "warm line" or "call-a-nurse" service. there is no institutional policy to support you when you are at home, in public, or taking a call at work.

we cannot stress enough how serious it would be if you were to take a call at home, or from a patient family if you were working on the floor, and give advice to them on something that would not be in your scope of practice to diagnose and treat.

one, you don't have any back-up in case of error. your malpractice insurance won't like it much, either. (you do have malpractice insurance, right? yes, you should have it as a student, and upgrade the day you graduate.)

two, if something goes wrong and the caller says, "wish_me_luck said i should do this!" it's her word against yours, and you have nothing to support you in an action against your license (and regular readers know that i am a big fan of not spazzing out about license loss; however, practicing medicine without a medical one can jeopardize the nursing one you hold).

three, your scope and standards of practice (you do have a copy of those, right?) probably does allow you to diagnose and treat many things. you can look in your nanda-i 2012-2014 for them (you do have that, right?), along with the characteristics that make the diagnoses. i can't think of a lot of those that a nurse could assess via telephone call, and certainly not a new grad winging it out in the world.

i understand that you're just trying to clarify a serious issue with incomplete information from your usual sources. i hope this is helpful and that things are clearer.

reading list: ana scope and standards of practice, your state nurse practice act, nanda-i 2012-2014. i've been out of school for mumblemumble years, and these are still within easy reach on my desk right now.

[imintrouble, BSN, RN]

Best of luck to you.

[wish_me_luck, BSN, RN]

imintrouble, why did you edit your post? I saw it before edit. I don't have a problem with opinions. I just want the best for my pts. The end.

[gallatea]

wish_me_luck

These are reasonable questions you are asking and it's better to ask, than assume and make errors...others making statements that you have a certain personality type is ignorant. I think part of the problem is so many women go into nursing thinking it's way more autonomous than it is. And many have BS/MS degrees and other prior degrees/careers before setting foot in a nursing classroom.

The higher echelon of students nowadays do ask bigger picture questions. I think a lot of the theory we learn/learned (not nurses 10-30 years ago) is elusive. On the other hand, I think instructors are vigilant about liability issues because we live in a very litigious society.

In the end though, the money to be acquired via a lawsuit is not in someone making 28/hr.. Pt's and lawyers go after the hospital and MD insurance. We might have to show up in court and explain our behaviors, but we are a very small cog in the wheel. (We "feel" responsible for everything because we are taught to "feel" this way, but it's an over-reaction through pedagody in my opinion in order to get our stubborn brains thinking in a certain way - or practicing in a defensive way.)

But I agree it's a confusing message - we need to know all the patho, pharm and now the trend is "anticipatory" nursing. Basically we will diagnose and presribe treatments IN our heads, but STOP at the point of total intervention (til we get the go ahead from an MD). (For example, getting meds ready because we know a certain condition is present, but we do not tell the pt. they have x dx or prescribe medicines just yet, but we def. NEED to know what's going on and get ready for it.)

And yes, their training is grueling. I live with an MD and after the 4 years of med school (and med school is 9-5, M-F, not to mention clinicals full-time), there were 6 more in training with 60+ hours per week involved. He would do 24 hr. shifts weekly in addition to 5 more days work. With NO summers off in between I might add. Then he did another 3 years getting a neuro pharmacology PhD - talk about a glutton for punishment. My training or clinicals were 8-10 half days per term in the first half of my program (2 years total for clinicals) (30 half shifts per year). Pretty wimpy in comparison, and I'd never want to bear all that truly weighs on his shoulders even if it's simply represented at times in one single aspirin. It's never as easy as it appears on the surface. Kinda like how everyone says, "OH I could do that, or a 5 yr. old could" of a Jackson Pollock or Van Gogh painting. That's not really the point. In the medical field, lives are on the line.

[wish_me_luck, BSN, RN]

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, "imintrouble" 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 "allnurses" 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 med calc 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.

[Double-Helix, BSN, RN]

First of all, no one is being hateful or needs to chill. We simply answered the question and kids was stressing the importance of following policies. We are answering your question, so I'm not sure where all the animosity is coming from... :icon_roll

Second, there very well maybe a time when you know more than the physician, especially if you work in a teaching hospital with interns and residents. However, that time is NOT going to be when you have just graduated. It's great that you can do thorough assessments and know all of that information about a disease. Physicians have to know everything that you listed (minus nursing diagnoses which you'll never use after school). In addition, they have to know what tests are required to diagnose problems, what medications and dosages to use to treat, what side effects and interactions there are between the medications, etc. Just because a physician might do the same assessment does not mean that you know as much about the patient's condition, history, disease process, and how to treat the condition. I can listen to a child with a heart defect and detect what type of murmur they have, and I can tell you the patho of their heart defect. But I'd be sorely remiss to think that I know as much as the cardiologist about how to manage that patient's condition.

I'm confused by your statement, "because we learn to do much more than what technically we can do." What you listed that you learned to do is an assessment. It is well within the nurse's scope of practice to assess all of those things. It is not within the nurse's scope of practice to draw diagnosis conclusions based on those treatments. Physicians go to medical school for 4 years, then they spend 4-8 years in residency and fellowship (think extreme clinicals) before they become licensed. Equating that amount of knowledge and education to four years in a nursing program is silly.

Yes, it is sometimes frustrating that I can't just tell a patient what the problem is and what to do about it. But you know what, that's not what I went to school for. If I wanted to prescribe medications, I'd go back to med school or get an NP. But physicians have much more liability than nurses. How often do you hear of a physician being sued for malpractice vs nurses? Those protocols and policies that are frustrating also protect our nursing licenses, so I respect and follow them.

[wish_me_luck, BSN, RN]

There's people on here all the time saying they are afraid of being sued or BON yanking their license. Plus, we were told that best practice is to get insurance; but at the same token, if the person knows you have it, they will take you to the cleaners if something goes wrong. We had to go to a BON conference (mandatory in my state) on professionalism and they scared the living pee out of us. It was regarding doing everything from malpractice to being under the influence. They opened up the licensing verification database with names of people who had info. against their licenses and clicked on it and everything. Plus, they have a magazine that they announce all the people who have something against their license from unpaid student loans to malpractice to drug use. So, unfortunately, I hear about it more than I would like to.

Anyway, enough with the physicians. I don't really want to talk about this anymore. Okay, bottom line, consult P and P manual.

[Sun0408, ASN, RN]

OP, only you would need to know if you had insurance or not. Those of us that have it do not wear a stick that says "sue me, Im insured". Im taking your statement lightly, no one needs to know, not a pt, their family or the facility you work in. That is a private matter for your protection.

Don't let your trip to the BON scare you, use it as a tool on how to keep yourself safe and those you are taking care of. My state also has a newsletter with names and info as well as the BON wedsite. Most of them that are on probation or lost their license was related to drug and ETOH abuse, DUI's etc.. BON is set up to protect the public from harm...

[OCNRN63, RN]

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.

No one was giving you a hard time. They were answering your question.