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their level of competence to perform specific tasks and activities, rather than face artificial barriers imposed by outdated organisational, industry based policies and legislation.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