Is It In Your Scope of Practice?
January 13th, 2012
By Jennifer Olin, BSN, RN
This week I have been talking about nurse practitioners broadening the scope of their practices in different states: how that would be beneficial, the organizations working for and against, and what some states allow and others don't. But it dawns on me the term "scope of practice" needs some definition.
As a nurse for a number of years, I think I know my own scope of practice. As a nursing student I heard the phrase a lot, read definitions, but they didn't mean much since I didn't really have any practices to fit into a scope—yet. So let's take a look at what the nursing scope of practice is and how it is determined.
To understand your nursing scope of practice you must first know what defines nursing. The American Nurses Association (ANA) provides a contemporary definition:
"Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations."
Ok, that sounds like a fancy variation on, "I want to help people." As nurses we commit to protecting the health of ourselves and others through education, hands-on care, and collaboration with other health care professionals. Those others we talk about can be found in hospitals, schools, neighborhoods, free clinics, doctor's offices and next door. So again, what determines if we are within our "scope of practice" to work with these other people?
We go back to the ANA and Nursing: Scope and Standards of Practice.
"The scope of practice statement describes the "who," "what," "where," "when," "why," and "how" of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The profession of nursing has one scope of practice that encompasses the full range of nursing practice pertinent to general and specialty practice. The depth and breadth in which individual registered nurse engage in the total scope of nursing practice are dependent on their education, experience, role, and the population served. "
Now we have this textbook definition. It tells us we must answer certain questions to know if something falls in our "scope" and it tells us there are lots of variables. Let's break it down because even though we all went or are going to nursing school, because we all have or will pass our licensing exams, doesn’t mean we belong everywhere. For example, I am an OR nurse. I know a lot about anatomy, technology, machinery and instruments, positioning, pressure points and personality quirks of my surgeons. I am not an ICU nurse. I know how to take a blood pressure, use my stethoscope, and I actually still remember the differences between wheezing and rales. I no longer know how to set up a pump, am unfamiliar with the many kinds of cardiac drugs used today, and haven't managed a ventilator since nursing school clinicals; those skills are not in my scope of practice.
Here are some guidelines determining your own "scope of practice:"
- Did I learn this skill or task in my basic nursing program? – Every nurse, everywhere should know how to take a manual blood pressure. It is a basic skill taught in nursing school.
If you determine that the activity was not part of your basic nursing program, try these questions.
- Did I learn this skill/task as part of a comprehensive training program which included clinical experience? – In my OR residency program I learned about electricity and its uses in surgery, how and where to properly place grounding pad to prevent burns and other electrical accidents. I learned how to pass instruments, including knives, safely to the waiting hands of the surgeon and how to assist the anesthesia provider with intubating the sleeping patient. All skills particular to the operating room environment.
- Has this task become so commonplace in nursing literature and in nursing practice (wound debridement and dressing, for example) that it can reasonably and prudently be assumed within scope? – At one time only doctors attended to patient's wounds, but wounds of all kinds — burns, diabetic, surgical — are so commonplace today that pretty much all nurses know or have been shown how to do it.
- Is the skill/task in your hospital's/clinic's/agencies' policy and procedure manual? – If it is in the book, your employer believes it is a skill/task that is part of the job you were hired to do—your "scope of practice."
- Does this skill/task pass the "reasonable and prudent" standard of nursing? – A large part of nursing is using common sense. Being reasonable and prudent is simply showing care and thought for the future—pretty much the basic tenets of nursing. If what you are about to do fits those definitions it is in your "scope of practice."
If you can answer yes to all these questions, the skill or task is within your scope of practice.
Scopes of practice are the same for every nurse at a basic level and very different by specialty (OR, ICU, ER, Telemetry, Pediatrics, etc.); education (LPN, ADN, BSN, FNP, CRNA, DNP, and all those other initials), where you practice and who you serve. If you have a question about something you are asked to do; if you are uncomfortable with something you see, maybe it's not in your scope of practice. It is always better to hesitate, ask yourself these questions and check with someone else before you commit your patient and yourself to a course of action you shouldn't be on. Stepping out of your scope of practice can be a legal issue and endanger that license you worked so hard for.
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As a nurse, one must follow a scope of practice, what is expected of them within their role of the nursing profession. These guidelines shape the responsibility of the professional nursing organization and serve to protect the public. According to, Nursing’s Social Policy Statement: The Essence of the Profession (American Nurses Association, 2010, p. ) defines contemporary nursing: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. ” I believe my role, as a nurse is consistent with the scope of practice outlined by ANA and the contemporary definition cited. As a nurse, I strive to be clinically competent and aware of the constant challenges that one faces on a daily basis.
Being well informed promotes health and prevents further illness and injuries. One goal I try to set aside every week is to attend a weekly ground rounds meeting, where additional education is provided on a specific case study. This opportunity allows me to stay current and up to date on new medications available, research findings and team collaboration feedback from staff on effective treatment options for optimal patient outcome.
In addition, completing required competencies and being a member of Oncology Nursing Society also strengthens my knowledge and skill in providing the best evidence based practice to an individual and their families. Being a resource nurse for my unit allows me the opportunity to share my knowledge with the staff and actively participate in mentoring young nurses build a strong foundation and develop critical thinking skills. Education is critical in the nursing profession. Lifelong learning must be an ongoing process due to the rapidly growing population and technology advancements in our society today.
I believe it is the responsibility of the nurse to facilitate this process and collaborate with other nurses in their field to continue to work together to strengthen the role of the nurse in an environment that requires continuous education and competencies. “Registered nurses must continually reassess their competencies and identify needs for additional knowledge, skills, personal growth, and integrative learning experiences” (American Nurses Association, 2010 p. 13). State legal regulations and professional standards of nursing The Ohio Board of Nursing defines nursing and the scope of nursing practice.
Rules and regulations are in place to determine compliance set in motion by the Nurse Practice Act. Responsibility is outlined by establishing standards for nursing education programs, eligibility to sit for the state licensure exam, renewal criteria of that license, and setting standards for continuing education to meet renewal criteria. The Board is also responsible for defining the standards of delivering safe nursing care for registered nurses and protecting the community with these standards.
Another role the Board is responsible for is reviewing and investigating violations of this Nurse Practice Act and determining if a nurses license is to be denied, revoked, suspended, or restricted in any way (Ohio Nurses Association). It is essential that nurses maintain an understanding of the legal regulations within their nursing practice. The Ohio Board of Nursing requires all Ohio nurses to have continuing education on Ohio law with a total of 24 continuing education hours every two years for license renewal (Ohio Board of Nursing).
As a professional, I feel it is my primary responsibility to understand the law and regulations defined before me, this knowledge allows me to safely practice nursing care and deliver the best care to my community. I have worked in other states as well, and of those states I have worked, Ohio is the only one requiring a continuing education credit with a focus on state law and regulations. I feel every state should have continuing education credit requirements for renewal and at least one of the required credits have a focus on law. It is important as a professional to have knowledge of this.
To have a check and balance system in place to make sure one is justly maintaining these standards and expectations in delivering a safe competent nurse to our community is vital to the population as a whole. Provisions 7, 8 and 9 “Provision 8 describes the nurse’s moral obligation to society. Provision 9 describes the responsibilities of the nursing profession to both the individual nurse and society in general. Provision 7 provides the necessary linkage between individual competence and evolving professional standards of practice, in addition to giving nurses a responsive and collaborative role n health policy for the overall advancement of the profession” (Fowler & Association, 2010, p. 91).
Initially, these Provisions were never intended to be carved out of stone, but historically, they have been a guide and continue to be a guiding force of moral and ethical standards to follow. I pride myself on working for a hospital that fosters an environment on ethical integrity and professionalism. Because of this strong thread, it motivates me to do more, achieve more, and be more than I am today. I want my patients and my community to feel that they are receiving the best nursing care.
An example I recently explored was implementing a grid to follow based on patient’s diagnosis and treatment pathway prior to admission to the floor. I work in the hospital’s rapid admissions unit. My goal is to have the patient to their room in 30 minutes or less. Of recent, we have received a lot of admissions for pancreatitis, however, I have noticed that the patient arrives to my unit without pain management options, i. e. PCA pump. This has delayed the patient’s comfort and care prior to arrival to HRAU leaving me scrambling to get pain orders, equipment and recover any customer service issues.
This grid allows a framework to use as a guide of anticipated orders and outcomes. I presented this grid to my nursing manager, our staff and the ER manager and charge nurses for their collaborative input and suggestions. So far it has been effective, and we are working on additional areas to cover as well. Nursing is continually evolving and as a professional it is our job to facilitate education within our community of nurses so we can better serve our patient population. Philosophical forces influencing practice
Philosophy is an attitude toward life and that attitude evolves from every nurses belief system. One’s attitudes are shaped by their environment and an accumulation of life experiences, I define nursing as a way to give back. Giving good nursing care doesn’t stop at being knowledgeable about medicine and having the very best in technology. It goes beyond, by reaching that individual on a spiritual level and connecting with them. I have always believed that one cannot be taught how to show compassion, an individual either possesses that ability or they do not.
I have always believed that that is one of my strongest qualities, and this has been reconfirmed back to me by my patients through the years. To truly interact with a person you need to gain their trust, once that has been achieved through a therapeutic environment, healing is then possible. Ethical principles influencing practice There are standards in place to dictate the need to protect patient’s values, beliefs, culture and safety. It is difficult at times, when dealing with challenging patients and having to handle the stress of our jobs to remain open and unbiased.
It is nice to have a reminder that our patient’s values come first and respect their choices. Our role is to educate them about their treatment plan and make sure they are well informed, while letting go of our own attitudes. Determining, nursing practice are essential for dealing with day-to-day ethical issues (Jormsri, Kunaviktikul, Ketefian & Chaowalit, 2005). I recently had an Asian woman who presented with abdominal pain and requested to have cupping performed by a healer specialized in the field. I was initially at a loss, how was I going to find someone to perform cupping.
I wanted to help this woman and when I asked my colleagues and manager they had no suggestions. So I contacted the department that handles cultural awareness and was able to get a lead on whom to call. After, two hours of my day spent looking for someone to call, I finally had my answer. I came back to give my patient an update on the progress and she was so relieved. It was like you could see the anxiety drain out of her. By the end of the day, the therapist arrived to do cupping with her and she was relaxed and expressed that she truly felt like I heard her.
It was not easy and I did find myself getting frustrated with the process of trying to make something work that I knew very little about. I’m happy I followed through with it, because in the end every patient has a right to believe what they believe, even though her values and attitude toward medicine is very different than my own, I was able to put aside my own views and attitude and really help someone else. Conclusion Many might say nursing is a science and some might say nursing is an art.
I believe it is both. To be a successful nurse one must have the passion to continue their education and apply their knowledge through the science of nursing, and have the efficacy and compassion to provide the art of caring. Without caring the nurse is unable to connect with the patient and if the nurse cannot connect, trust will not develop between the nurse and the patient. I have always believed nursing is a calling and it is one of the most challenging jobs to have, but by far it has been the most rewarding.