Understanding Nursing Scope of Practice (Part 3)

Where do I get my Authority?

So where do nurses get their authority to practice from and does this authority vary across different roles, activities and functions? Part of the confusion is that our authority comes from a wide range of sources.Nurses have authority to practice by virtue of the fact that they are regulated health practitioners within a regulated health profession (as determined by legislation –The Health Practitioner Regulation National Law Act). This means that nurses on the register can use the protected title ‘nurse’ and practice within the authority given them by the Act (the regulation).

•Under this legislation nurses are afforded further authorisation through professional and regulatory standards endorsed by the regulatory body (the Nursing and Midwifery Board of Australia (NMBA) and the Australian Health Practitioner Regulation Agency (APHRA). The Board endorses standards that define and determine our professional practice. These include the National Competency Standards for the two levels of nurses, Codes of Ethics and Professional Practice and a range of Professional Guidelines outlining professional obligations such as the requirement for completing mandatory continuing professional development. APHRA endorses standards specifically related to our regulation such as, registration types, specialist registration and reporting obligations. All of these regulatory standards/codes and guidelines outline (and provide authority) for us to practice as a nurse.

There are any number of other standards, codes and guidelines endorsed by different professional associations. The Australian Nursing Federation  (ANF) in partnership with other professional organisations, has endorsed a number of competency standards such competency standards for Nurses in General Practice. Other professional associations for specialist clinical practice areas may also have agreed competency standards such as for Mental Health Nurses, Asthma Educators etc. Most of nurses evidence based clinical practice policies/procedures and guidelines are endorsed by government (eg Department of Health in each state/territory) or at a local level by the employer. Clearly then, an individual nurses authority to practice may be primarily linked to the policies or the organisation in which the nurse is employed  (and so vary significantly from one workplace to the next). This only adds to the confusion as it may mean that a nurse who is competent in a particular clinical procedure may or may not be able to perform this procedure in an organisation that has a policy restriction this practice. A common example of this is enrolled nurses and medication management.

Our authority is also determined by our own level of competence. Our level of education, knowledge and skill determines those activities and functions that we are competent to perform. We are required to be self regulating in that we self assess own competence and our continuing professional development needs to maintain, enhance this competence. So determining our level of authority can be a very complex decision making process. We are often unsure whether a particular policy in our workplace has been determined because it is a regulatory requirement, a legislated requirement a government requirement or solely the decision of our employer.  And as so much of our clinical practice is not entrenched in legislation, it can be influenced by workplace culture and history than by emerging contemporary practice.

4 Levels of SOP Decision Making

So we can see from the sources of authority that scope of practice decision-making takes place at four distinct levels.

Regulatory – through the Board (Nursing and Midwifery Board of Australia) and AHPRA (Australian Health Practitioner Regulation Agency). The Board sets standards, establishes expectations and assists nurses to make accountable, evidence based decisions within their scope of practice. Regulatory decision making includes consideration of all legislation that impacts or is impacted upon by nursing practice.

Professional – through peak bodies, professional nursing associations. The nursing and midwifery professions, through peak national and international bodies, professional discussion and debate, establish clear parameters through professional guidance, education and policies to support scope of practice decision making. The professions understand, reflect and contribute to and advocate for amendments to legislation to enhance nursing practice.

Organisational – though workplace policies and procedures, these may be influenced by government protocols and/or legislative requirements or by organisational culture. Employers, directors of nursing and other key collaborative health professionals and providers develop and review policy and practice that determines the practice of nurses in their workplace. These policies influenced by the health needs of their client populations and should support the expansion of nursing scope of practice reflective of meeting client needs and expectations. Organisational decision making and policy also needs to reflects all legislative obligations in relation to nursing practice.

Individual – the nurse makes decisions and uses professional judgement based on their own knowledge, skills, expertise and level of responsibility and accountability. Nurses, in a context of self-regulation and self-assessment of continuing competence, should consider their scope of practice and make decisions based on education, experience, knowledge, competence, skills and the workplace environment. 

Scope of practice decision-making can occur and/or be instigated at any of these four levels but interdependent and interactive across the levels. Further, for nursing practice to be effective, and underpin the autonomy of the profession, it should be a supportive (not punitive or restrictive) process and should work to facilitate best practice.

Scope of Practice decision making requires the nurse to consider a number of factors to determine whether to move forward with an activity of function, to seek further advice or to refer to another health practitioner. By considering each of these factors a nurse can make a decision about whether the activity function is within their scope of practice to perform or whether it more appropriately within the role of another health practitioner (within the same profession or another profession).

As registered nurses have the added responsibility for the supervision of and delegation to enrolled nurses, part of their scope of practice decision making will be in relation to the level of supervision and the appropriateness of delegation to an enrolled nurse in each circumstance. As we have a previously identified that scope of practice is determined by many variables a decision about whether or not a function or activity is within a nurses’ scope of practice must be based on assessing these variables. Remember they include regulatory standards/protocols, professional standards/protocols, workplace policy, own level of competency and accountability held and the needs of the client/population. A simple linear decision-making tree then,  can assist us to consider all of these variables as part of our decision making.

Example

Lets look at an example of scope of practice decision-making and how you can use the decision making process.

An Agency RN is is sent to an Aged Care Facility on a late shift. It was a last minute booking due to sick leave so when she arrives the day shift RNs have left and its after 4pm. An EN is rostered on duty with two Nursing Assistants.  The EN gives a handover and then raises the matter of the medication round. “’I’ll do the drugs up my end and you do them this end” says the EN. The RN thinks to herself……”What do I do, I don’t know the EN or whether she is competent. I don’t know the policy here either. What if she makes a mistake…am I accountable? Should I do them all? HELP!”

So how does she make this decision?

If she uses the SOP Decision-Making Tree she should consider the following…

1. Will the clients of the NH benefit from the EN giving medications in one wing and the RN in the other?

The RN does not know the clients and does not have time to familiarise herself with their case histories in detail.The EN does know the clients and their conditions and their medications. Also the EN would recognise subtle changes in health status of the clients as she is familiar with them

Two staff administering medication means that the clients will receive their medications on time (without extended delay due to 1 RH who is not familiar with them). YES – a client benefit is identified.

2. Is the activity within the practice of the profession?

This often a point of confusion as some ENs have current medication competency and others do not.  How does the RN identify this? (ASK!) The EN is also accountable for being competent and practicing within her scope of practice so she would be able to verify if she is competent. (some workplaces have competency sign off books so the EN may be able to present this as evidence.  However this is not required and an RN can ask a few simple questions to identify if the EN has current skills in this activity. Why would the RN not assume that the EN, as a health professional, would tell the truth. If the EN responded that she had not administered medications recently then the decision to delegate changes.  In this instant the EN has indicated by her comment, that she assumes she will be giving the medications and by her comment, that this is a common practice.

The RN could also recall that there have been changes to regulatory requirements for ENs and medication administration and if the EN was not able to administer medications this would be noted on her practicing certificate.YES – within the ENs practice and within the practice of many other Ens.

3. Is there a policy in place?

This is one of the key variables as some workplaces do not allow ENs to administer medications whilst others do. Again, the RN could merely ask the EN what the policy is in the NH.  If the EN has made an assumption that it is routine for her to administer the medications and that she has current competency then it seem reasonable to expect that it is routine policy within the facility.  If the EN was to say that some RNs let her give the medications and others didn’t then it would need to clarify the policy (and perhaps ask to site it). There are also many examples of standards and guidelines from professional bodies supporting medication management as part of EN scope of practice.In this case we will say YES the policy is in place as medication administration is a routine activity on late shifts when there is only 1 RN

4. Is the EN the most appropriate person to perform the activity?

The RN has considered this in relation to meeting client needs. Where there another RN this would not be the decision. In handover and in further discussion with the EN, if it was identified that several clients were unwell or unstable, or if medication regimes had recently changes, the RN may decide to assess these clients herself and review their condition whilst administering their medications. If it was identified that a number of clients were on prn medications this may also be her decision. In this case it is identified that the client care is routine and medication regime unchanged so the RNs decision is that the activity is within the ENs scope of practice and  to delegate the activity.The concern that if an EN makes an error that the RN is accountable for that error is a fallacy. Both RNs and ENs are accountable for their own decisions and actions and the consequences of their decisions and actions. 

Simply explained (and without prejudice). The RN cannot be accountable for the decisions and actions of another nurse. If the EN make an error, they are accountable for that error and the decisions/judgment they made and how they performed the activity resulted in the error.  The RN is however accountable for the supervision of and delegation to the EN. 

What does this mean?

If for example the RN delegated a procedure to the EN that was outside of the ENs level of competence, but told the EN to do it anyway, the RN is accountable for inappropriate professional judgement in delegation. (Note: the EN is still accountable for performing a procedure that they were not competent to perform – they should have refused to accept the delegation). If the RN failed to appropriately supervise an activity performed by the EN and that lack of supervision contributed to the error occurring, then the RN is accountable for poor supervision (again the EN is still accountable for the actual error). In both of these instances the RN is accountable for her decisions and actions – ie decision about the level of supervision required and decision to delegate activity. The EN is accountable for the error. If the RN made a sound decision about both supervision and delegation but an error occurred – the EN is accountable for the error .

Understanding and articulating your scope of practice

As we are now required to complete annual Continuing Professional Development as part of our evidence of competence it important to be able to articulate our own individual scope of practice as part of this evidence. Consider writing a short (no more than 500 words) statement of your scope of practice. You can use a set of questions to assist you in structuring your thinking. Once you have done this type it up without the questions and sign and date it. You can include this in your portfolio.

Consider the following questions;

What is my level of education?

Do not rewrite your qualifications as this is already contained in your CV. Document the level of qualification you have achieved and the area of study your have focused on

What is my level and area of competence?

Again, do not write a list of procedures but rather document your broad skills, knowledge and area of practice and refer to the Competency Standards (the language in the Competency Standards may assist you)

What am I authorised to do?

Write your broad functions and duties and the level of accountability.

Date and Sign

This formalises the document and validates it as evidence.

Understanding Nursing Scope of Practice (Part 2)

Most nurses are also clearly able to self assess what they are competent and what they are not competent to perform. It is more difficult however to determine what we are authorised to perform as our professional

One must consider professional scope of practice in context with changing expectations, practices, client needs, the changing health care system and the expanding expertise of the profession.  Internationally, nursing is moving towards a broad, enabling scope of practice. These broader scopes of practice support health practitioners to make decisions about and within their competence and the environment/setting in which they practice.

By supporting and facilitating nurses to make appropriate decisions about their practice, we are moving away from overly prescriptive policies and procedures that restrict practice based on historical and cultural practices. We are also moving away from the need for routine certification of tasks and activities and focusing on annual continuing professional development and self assessment of own competence. Individual nurses, as regulated health professionals, should be able to make decisions about their level of competence to perform specific tasks and activities, rather than face artificial barriers imposed by outdated organisational, industry based policies and legislation. In doing so however, nurses must have a sound understanding of scope of practice decision making to achieve this.

Challenge…Role Confusion

Nurses cannot make clear and sound decisions within their scope of practice if they do not understand their scope and limitations of practice. One of the key challenges is that the practice of nursing is so broad that an element of role confusion is almost inevitable. Add to this, nursing is one profession with two levels of registration, differentiated by levels of accountability and decision making (not competence). Further there are few nursing tasks or procedures that are protected practice and are therefore able to be performed by other health professions and providers, including unregulated healthcare workers. Therefore the tasks performed by nurses do not distinguish nursing practice from other providers.

Though the title of nursing is protected by legislation, the practices within our professional aren’t! It is the roles and responsibilities related to coordinating care and the knowledge and skills utilised by the nurses determining and providing the care, that distinguishes the nurse – not the task itself. It is a concern then that all too often nursing policy is task focused rather than scope of practice focused and limits the enhancement and expansion of nursing practice.

There are other drivers however that the nursing professional can utilise to assist them to enhance their scope of practice and decision making. There is clear support from government and employers to ensure availability of a cost effective mix of health services and providers. We have been moving towards health reform agendas for some year, both at a state and national level. There is an increasing focus on primary health care models of service delivery, where nurses excel and are cost effective and efficient.

With the need to refocus health care delivery in the community (and away from tertiary health care services) provides an opportunity for nurses to be at the forefront of service development, design and practice. With these changes there is a need for new profiles and roles for health care providers and a need to better design roles.Nurse led primary health care clinics, health promotion and prevention programs, home visiting, transition from hospital to home. There is also growing expectation of the public, as healthcare consumers, for improved access to cost effective health services.  Nurses have the perfect opportunity to expand into these roles.

The Nursing and Midwifery Board of Australia (NMBA) has endorsed national decision-making frameworks for both nurses and midwives. These two flowcharts are designed to assist nurses (and midwives) in their professional decision making through a structured and transparent process. It also provides the nurse with and an evidence-based process (approved by the regulatory authority) in their decision-making that they may use in support/defence of their decisions should they be required to provide it.

Scope of Practice Principles

In defining Scope of Practice there are several principles that ensure broad enabling definitions. Scope of practice frameworks should provide reasonable direction of appropriate parameters for professional practice. These parameter should clearly articulate the breadth of the nursing role without prescribing specific tasks or functions that are self limiting rather than enabling the nurse determine the appropriateness of their role. Definitions should describe nursing activities, tasks and functions so as not to inappropriately limit nursing practice or the ability to meet individual and population needs or prevent  or to prevent nurses from responding to individual client or client population needs of from adapting to change.

Scopes of Nursing Practice must be consistent with national competency and role standards, guidelines and codes, (ANMC National Competencies and NMBA Standards) and reflect international definitions of and positions on nursing practice (such as the International Council of Nurses www.icn.ch)

Finally scopes of practice should recognise and reflect that nursing is practiced in a diversity of environments and communities and as such, must adapt to meeting the specific and unique needs of these settings. Nursing Scope of Practice frameworks should recognise and acknowledge that nursing is practiced in a broad wide range of areas, not solely direct clinical care.

The Nursing and Midwifery Board of Australia has defined “To Practice the Profession” as being:

“any role, whether remunerated or not, in which the individual uses their skills and knowledge as a health practitioner in their profession. For the purposes of this registration standard, practice is not restricted to the provision of direct clinical care.

It also includes using professional knowledge in a direct nonclinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession”. (Fact Sheet Registration Types AHPRA April 2010).

Scopes of Practice must be driven by and promote safe and competent nursing practice. They must be flexible enough to be responsive to change in community/client health care needs. They must further provide appropriate information to consumers of health care services to enable them to make informed choices about the nursing care services they access and receive and to evaluate the practice and standards of nurses who provide their care.

A Nurse’s decision making within and about their scope of practice needs to structured and based on a defined framework, set of guidelines or tool that assists them to make informed and transparent decisions consistent with the expectations of the profession and the regulatory authority (Nursing and Midwifery Board of Australia). Any Scope of Practice tool should support the nurse, and facilitate their thinking and judgement and guide their decision making process. It can also be used by individual nurses, to self assess their practice, reflect on their competence to make appropriate decisions. In particular it enables registered nurses who are autonomous in their decision making, to assess their critically review their competence to understand and interpret their scope and limitations of practice.

SOP of the Profession

So, is there a difference between the scope of practice of the nursing profession as a whole and the scope of practice of individual nurses? In truth our scope of practice is influenced by so many factors that each individual nurse would have a unique scope of practice, even as undergraduates, students have difference clinical placements and are exposed to diverse clinical settings, client groups and procedures even though they are undertaking the same course. The scope of practice of the profession is the broadest context of practice, the outermost limits of professional practice under which all nurses practice.It includes the broad and diverse range of roles, activities, functions, responsibilities and decision-making capacity within which all nurses practice. It is informed by all of the factors that influence (and therefore diversify) our practice and includes the setting and environment in which we work, the policies and procedures that we are bound by (both those specific to our employer and those established by government and the profession), our level of education and experience, knowledge and skills, professional standards and codes of practice, legislation, the types of professional judgement and decision-making we are accountable for and the health needs of the population.

SOP of the Individual Nurse

The scope of practice of the individual nurse then is different from that of the profession. No nurse can be competent to perform all of the range of roles, activities and functions etc. How then do we know what each of our individual scope of practice is? It is clearly more specifically defined than the scope of the profession as each nurse must be able to determine what practices and responsibilities they are able to undertake. The scope of practice of a nurse is that which they are EDUCATED, AUTHORISED and COMPETENT to perform. 

Nurses must assess these components relevant to their own practice to determine what is within and what is outside of their scope of practice. 

Most nurses are comfortable with assessing and articulating their level of education and knowledge.  A nurse’s authority comes from a number of sources and nurses (and employers) are often unclear about what level of authority is required in different circumstances. One of the most misunderstood issues in relation to authority relates to the to role distinctions between the registered and enrolled nurse.

References:

Nursing and Midwifery Board of Australia Continuing Professional Development Registration Standard – www.ahpra.gov.au/Registration-Standards  

Nursing and Midwifery Board of Australia www.nursingmidwiferyboard.gov.au

International Council of Nurses (ICN) www.icn.ch

Australian Nursing and Midwifery Council (ANMC) – the ANMC was restructured in 2011 to become the Australian Nursing and Midwifery Accreditation Council (ANMAC) and provides accreditation of overseas nurses and midwives seeking registration in Australia and accreditation of courses leading to registration as a nurse or midwife. The ANMC Competence Standards are now available on the NMBA website.

Registrations Types Fact Sheet Australian Health Practitioner Regulation Agency (AHPRA) Fact Sheet 2010 www.ahpra.gov.au  

ANMC A National Framework for the Development of Decision-Making Tools for Nursing and Midwifery Practice 2007 www.nursingmidwiferyboard.gov.au