Scope of practice ? RN able to perform task ?

[clomicka]

Would like consensus from fellow nurses whether they believe this falls under the scope of practice for RN in Florida without peri-op or RNFA program (additional certification).

Job entails the RN without direct supervision of a MD/PA/NP/DO in a office practice to perform the following:

application of injectable anesthetic under the skin, clean site, insert surgical trocar instrument subcutaneously parallel to skin, insert medication through trocar then remove instrument, maintain hemostasis, use of steri-strips/suture. Example procedure can be found Hormone Pellet Insertion Procedure | Trocarkit – Trocarkit.com.

Comments appreciated.

[hppygr8ful, ASN, RN, EMT-I]

You would have to check the scope of practice in your state as this may be highly state specific - Check with your state BON as random opinions from strangers is never a good way to make decisions.

Hppy

[MunoRN, RN]

There is no single scope of practice for nurses, it depends on what you've been trained to do with a verified competency that isn't specifically prohibited, and the insertion of subcutaneous medication delivery devices is not generally prohibited, it's actually a pretty common thing for nurses to do.

What is a potentially bigger issue is the position some BONs take on non-medically indicated hormone therapy, which some BONs consider it inappropriate for RNs to take part in due to the potential for risk without any established benefit.

[clomicka]

Did ask them and they wanted the RN to submit a Declaratory statement to them. Thanks

[clomicka]

I agree it is not FDA supported but more clinics are performing these procedures and training classes only train MD, DO, ARNP, PA to do the procedure since it is considered a surgical instrument. The tricker part is the RN is able to adjust the dosage of the medication based on the patient's symptoms even though dose of medication ordered by MD is done by labs. I was just trying to verify what education is normally required and how many hours for an RN with 2 year degree to use a surgical instrument and deliver medication that is being dosed by RN not MD/ARNP.

Thanks for the feedback

[clomicka]

Also, doesn't RN tasks usually need a supervising MD/ARNP/DO in the room to perform these tasks ?

[MunoRN, RN]

I agree it is not FDA supported but more clinics are performing these procedures and training classes only train MD, DO, ARNP, PA to do the procedure since it is considered a surgical instrument. The tricker part is the RN is able to adjust the dosage of the medication based on the patient's symptoms even though dose of medication ordered by MD is done by labs. I was just trying to verify what education is normally required and how many hours for an RN with 2 year degree to use a surgical instrument and deliver medication that is being dosed by RN not MD/ARNP.

Thanks for the feedback

I don't know that there is any regulatory definition that is solely based on the use of a "surgical instrument", forceps are a surgical instrument, but that doesn't mean it's out of a nurse's scope to use forceps. Entering into a cavity or space that requires dissection to get into would typically be considered 'surgery' and out of an RN's scope, but inserting a device into the subcutaneous space wouldn't usually count as that.

A non-licensed person could work 'under the direct supervision' of the MD and be working under the MD license, which might be a better alternative, although both would be exposing themselves to significant liability given the lack of potential benefit vs risk when used with a valid medical indication.

[KelRN215, BSN, RN]

Also, doesn't RN tasks usually need a supervising MD/ARNP/DO in the room to perform these tasks ?

In general, when does an RN task EVER require supervision of a Physician or Nurse Practitioner?

If it's something in the RN's scope of practice, it's in her scope of practice. I have never, in 11 years, been supervised by a Physician when doing anything within my scope of practice.

[AceOfHearts<3]

Also, doesn't RN tasks usually need a supervising MD/ARNP/DO in the room to perform these tasks ?

Really? You have an MSN and you are asking this?

[clomicka]

There has been an incident in the office; after researching very gray area scope of practice and calling the board of nursing left me to believe it is not an issue (no Liability Insurance for this RN) - AORN mentioned with Medical Boardhas ruled in legal matters in previous declaratory statements filed in the state ruled against the RN to perform incisions and and this was either MD,RNFA's, CNS's and NPs and required training of First surgical assists.

So what tasks are you RNs performing similar to this ?

[clomicka]

AceOfHearts

[Medic/Nurse, BSN, RN]

As a flight nurse, I had competencies and protocols (no supervision) for surgical cricothyrotomy and chest tube placement.

This is not Florida, but my state BON required physician clearance, written protocols and (here is the biggie) PHYSICIAN VERIFIED COMPETENCIES. Meaning I would be doing procedures that the PHYSICIAN verified that I could do - beginning to end.

Now, tho I am competent to do these (and more) in my ROLE as a FLIGHT NURSE, if I were to do these in my staff nurse role I would expect to get my ticket pulled by the BON.

I also had various protocols to determine dosing of medications based on MY JUDGEMENT and PATIENT PRESENTATION.

Fact is I could also get a PHYSICIAN in direct communication and be advised/authorized, if an extraordinary circumstance presented, to do most anything AS LONG AS THE MD DETERMINED I COULD DO THE ORDER SAFELY. Now, that didn't mean I could forego good nursing judgement, AND I have refused MD DIRECT ORDERS (as a medic, not flight nurse, but really the same principle) as contraindicated or unsafe (then I better be prepared to be able to justify my actions/inactions of the refusal, if questioned or based on patient outcome in some circumstances).

Protocol driven care is a fairly standard practice in the flight realm. If written protocols covered every possible patient situation, the helicopter could not take of with that protocol book on board.

And my nursing degree is ADN. So...

Not sure why an ADN is the issue, or why that matters in your situation, as BON's (to my knowledge) do not grant BSN (or MSN) prepared nurses with special nursing licenses. Yes, I know NP's get special licenses, but that is not what we are referencing and those are not just granted due to graduation with a degree (got to pass NP Boards).

I hope this makes sense to you.

:angel:

OP, I hope this is not over care that was provided to you or someone in your family, my gestalt of this was it seems personal. Florida Administrative Code uses this for extraordinary circumstance , not a practice complaint process. You must be a "substantially affected person" to seek a declaratory statement (BON's try to limit these) and best person to request interpretation via DECLARATORY STATEMENT is someone personally affected by the question being asked - meaning generally the nurse themselves, tho others (employers and supervising MD's) may show themselves to be a substantially affected person within a limited set of circumstances.

I would think that the answer to your question asked would be obvious to the PHYSICIAN in consultation with an experienced HEALTH CARE ATTORNEY as it appears the BON in Florida looks at education/training/verification of competencies, written protocols, physician oversight and their willingness to take responsibility for the safe practice of person he authorizes to do the same.

Declaratory Statements are very complex instruments and thus, expensive, to do well and are not generally done without an attorney.

Good Luck.