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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Jovanna Rios 11/25/13 Pharmacology is the study of the physical, biological and chemical actions of drugs (Bryant & Knights, 2011). In the practice of medicine, drugs are used to diagnose, treat or prevent disease so for the registered nurse in a clinical setting, the knowledge of pharmacology plays a huge importance in their role of medication administration. Pharmacology knowledge allows the nurse to carry out safe medication administration, monitor medication actions, educate patients, and act legally and ethically within the pharmacological parameters.
This knowledge is also vital for the nurse practitioner in their role of nurse prescribing. Pharmacology plays a huge part in these roles for the nurse. This essay below will elaborate on the importance of pharmacology for the five reasons of safe medication administration, monitoring of medication actions, patient education, legal and ethical aspects of pharmacology and the nurse practitioner. Firstly, safe medication administration. To administer drugs safely it is the nurse’s responsibility to have knowledge of the prescribed medications as well as their therapeutic and non-therapeutic effects.
Knowledge of the medications include, knowing its approved drug name and classification, correct dose and route of administration. A medication may have as many as three different names- a chemical name, a generic (proprietary) name and a trade name (Crisp & Taylor, 2011). A chemical name refers to the chemical makeup of a drug, a generic name is the drug name listed in official publications such as the MIMS annual, and the trade name is the name manufacturers have registered the medication as.
In a clinical setting medication is normally dispensed using the generic name to avoid confusion, but because medications may come under a number of different names nurses must be able to identify the exact name and spelling so that the right medication is given. With every medication comes its dose range and form. With knowledge of pharmacology the nurse should know the correct dose, form (e. g. capsule, ointment, syrup) and frequency of a drug. This is vital for safe administration. The routes of drug administration fall into many major categories being oral, parenteral, inhalation and topical.
A nurse’s knowledge of pharmacokinetics (what the body does to the drug), and pharmacodynamics (what the drug does to the body) (Lecture notes, 2011) both subdivisions of pharmacology, allows them to choose the right route based on the assessment of the patient, the speed at which they want the drug to be absorbed at and the magnitude of the therapeutic response that results (Bryant & Knights, 2011). As well as these points nurses must use the five rights of medication administration to safely administer drugs. The five rights being, the right medication, right dose, right patient, right route, and right time.
Having sound pharmacology knowledge allows the nurse to apply all these, correctly in the medication administration process. Monitoring medication actions is another huge part of the nurse’s job as they are in frequent contact with patients in regards to medication therapy. Pharmacokinetics and pharmacodynamics play an important part in this role. Medications can vary in the way they act and the type of actions they produce, and there are also many factors that influence these actions. Factors include therapeutic effects, side effects and adverse reactions.
Factors also include toxic and allergic reactions. A therapeutic effect is the expected or predictable physiological response a medication causes (Crisp & Taylor, 2011). This is the best results for the patient and can be achieved if the nurse is highly knowledgeable in pharmacology. Side effects, adverse reactions, toxic and allergic reactions are negative effects. In saying this nurses apply the knowledge of pharmacology should any of these occur by modifying the therapy, or discontinuing the medication. With limited knowledge the nurse may not know what to do should this situation ever occur.
This can also result in medication errors. The nurse’s understanding of pharmacology is important in her role of educating patients about their medications. The nurse must be able to answer any questions the patient may ask about their medications, such as why they are being taken, and consequences of not taking them. Knowledgeable nurse educators are able to make patients feel like experts with regards to their own medications. According to Barber and Robertson, “The nurse should be able to educate to the extent that they and the patient feel confident with their medication management”.
Having a firm grasp of pharmacology principles will allow the nurse to do this, again highlighting the importance of pharmacology. Because nurses administer drugs to patients they are legally accountable for their actions. There are also many ethical principles that apply to drug use. In regards to legal accountability the nurse needs to practice within the laws that govern her scope of practice and the laws relating to the control and regulation of drugs. The understanding of these laws, combined with good judgment, clinical skills, and pharmacology knowledge ensures safe and appropriate nursing practice.
If the nurse is not knowledgeable about the laws around drug use they could be putting patient’s lives at risk. Not abiding by these laws can result in loss of nursing registration. With regards to ethical principles this puts responsibilities on the nurse to practice ethically. This includes non-maleficence (doing no harm), beneficence (doing well), justice, veracity (telling the truth), maintaining privacy and confidentiality, and autonomy of the patient. In order for the nurse to practice ethically they must be competent and up to date in their practice including pharmacological knowledge.
The importance of pharmacology in regards to these ethical principles is that it helps the nurse achieve them. For example non- maleficence, the nurse uses their knowledge of pharmacology to safely administer, and monitor actions of the medication. Sound knowledge allows them to do this safely with no harm, and can also coincide with beneficence because the nurse knows they are doing well. For justice and veracity, the nurse maintains fairness and has the duty to tell the truth to the patient about their medications so pharmacology knowledge helps them explain that to the patient.
As with privacy issues and confidentiality, nurses must always maintain this in dealing with patients. For autonomy, the nurse promotes the right of self-determination and recognizes patient self-worth by encouraging them to participate in decisions about their health. Having pharmacology knowledge allows them to do this by making patients more knowledgeable of their medications. A nurse practitioner is a registered nurse who has studied at an advanced level and is licensed to prescribe drugs. Because of this unique role in patient care, it is critical they have an advanced knowledge of pharmacology.
This is because of their prescribing rights, so they must know everything there is to know about prescribing lawfully and safety. As new medications are introduced regularly, continuing education is essential for nurse practitioners to keep abreast of the latest pharmacological trends. In conclusion pharmacology knowledge for the nurse and nurse practitioner is essential for the safe and effective care of patients. When drugs are involved it is important that they are used in the way which best benefits patients, so that they can achieve better health for themselves.
As new drugs are regularly introduced to the world it is important nurses continue their education, to keep up with the latest advances in pharmacology. As mentioned above in the five reasons of safe administering, monitoring adverse reactions, education, legal and ethical responsibilities, and the nurse practitioner, pharmacology knowledge plays a huge role. Without pharmacology knowledge patient’s lives are put at risk, and many more medication errors would occur hence its importance.
- Barber, P. , & Robertson, D. (2009). Essentials of Pharmacology for Nurses. Berkshire, England: The McGraw-Hill Companies.
- Bryant, J. , & Knights, K. (2007). Pharmacology for Health Professionals (2nd ed. ) Marrickville, N. S. W: Elsevier Inc.
- Collins, S. , Lilley, L. , Harrington, S. , & Snyder, J. (2011). Pharmacology and the Nursing Process (6th ed. ). St Louis, MO: Mosby Inc.
- Crisp, J. , & Taylor. C. (2011). Potter and Perry’s Fundamentals of Nursing (7 ed. ). NSW, Australia: Elsevier Inc.
- Manukau Institute of Technology. (2011). Pharmacology Lecture notes. Otara, New Zealand: Manukau Institute of Technology, Department of Nursing and Health Studies.
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