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.
Once you have a professional diagnosis from your physician, you can work out a dietary or an alternative approach to drugs. steak n shake for diabetic food
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