Nebraska — Edition 24
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The Quest To Locate “Scope Of Practice” For Neb. Nurses
Annet te Schnel l MSN, APRN-PCNS-BC, CPN; Joan Batenhor s t BSN, RN, CPN; and Kay Ryan RN, Ph.D. , CPN

The Quest to locate “scope of practice” for Nebraska Nurses

In the Spring 2010 edition of Nebraska Nursing News, our State Board of Nursing Executive Director Diana Baker shared some real life issues around many Nebraska nurses’ lack of familiarity with the Nurse Practice Act.

We wholeheartedly agree with Diana’s findings. Nurses are busy “doing” and may not take the time or may lack skills or direction to navigate the technology in order to find or understand the regulations that define the scope of our nursing practice in the state of Nebraska.

For example, when we asked several Nebraska nurses about their scope of practice, they indicated they understand what scope of practice is but don’t know where to find it, who defines it, or where to go for specific information regarding appropriate and inappropriate nursing interventions. So, for the sake of the “average bear,” we want to walk through an exploration of how to find information regarding a Nebraska nurse’s scope of practice. We bring you two Nebraska nurses’ experiences in their quest to answer a sample scope of practice question: “Is it within our nursing scope of practice to replace a gastrostomy tube on a patient?” Our first nurse would qualify herself somewhere in the middle range of being technologically savvy. She takes us through her journey of Internet wandering in search of the Nebraska nursing scope of practice and makes note that the first time around, it was not a direct path to the desired information.

So… let’s get started: Go to Google Home Page and type in “Nebraska RN” – seems obvious, but when she tried other versions they did not provide the top choice of the website that she was seeking. This entry directed her to what she was looking for: www.hhs.state. She hoped that the website would basically give the “list” of things that a registered nurse is allowed to do. There are a number of links, but the “list for Rns” was not one of them. Under the link titled Practiced Defined, there is a nice outline that helps assist the LPN and LPN-C related to IV activities. The other item under the link “Practice Defined” is the Scope of Practice Decision Tree. She reviewed this several times to understand how it can guide to what should be on the “list” she was looking for. The reality is, it is pretty clear on what should be in the scope of practice for a nurse, but again is just not a detailed “list.” This is what she discovered: as you follow the algorithm to find what is acceptable practice, you must return to your roots, in some cases, like what is taught in the basic nursing program (a few years ago for her); what is included in the national nursing organization standards of practice; what is supported by nursing literature and research, established policy and procedure in the place of employment; and what is addressed by a Nebraska Board of Nursing advisory opinion. Of all these options, the Advisory Opinions was the jack pot “list” as it clearly provided specific tasks, procedures or roles that outlined acceptable practice for a nurse scope of practice. It just did not include everything a nurse could do.

Our second nurse is considered a technologically savvy individual. When she first started on the quest to find out what was included in her scope of practice as a Nebraska nurse, she went to Google and typed in “Nebraska nurse scope of practice”. The first website displayed was the following address within the Nebraska Department of Health and Human Services website: nursing/rn-lpn/rn-lpn.htm. This link took her to the RN/LPN home page which she hoped would lead to a document that explicitly stated what acts Nebraska nurses can/cannot perform. Instead, she found multiple choices along the left side of the home page. Among these options was the “scope of practice decision tree”. This title caught her interest since it was the only choice that mentioned “scope.” When she clicked on this option, she found an algorithm that was developed to guide a Nebraska nurse’s decision about whether a certain act was within their scope. The decision tree displayed an organized, stepwise approach to guide nurses.

In an effort to understand the process by which a nurse determines if a practice is within their scope, she returned to the topic of replacing an abdominal gastrostomy tube and worked her way through the decision tree. According to the decision tree, after defining the act to be performed, the next step is to determine if the act is “expressly permitted or prohibited by the Nursing statutes.” This may be the last step necessary to determine if the act is within a nurse’s scope. Referencing the nursing statutes (particularly 172 NAC 99- Provision of Nursing Care) provides an overview of standards pertaining to delegation, direction, assignment and the minimum standards within the framework of the nursing process. The only specific actions that are mentioned are intravenous cares by LPNs. No mention is made of gastrostomy tube replacement. At this point, our “techie” nurse got stuck, so she navigated down the decision tree to step three, which addresses if substantial specialized education or training is necessary to perform the act. Specialized education or training includes education beyond basic education for licensure and independent judgment. When considering the act of replacing an abdominal gastrostomy tube, she determined that specialized training is necessary for this action, which would limit the act to Rns and APRNs, according to the decision tree.

Step four further helps to determine if the act is appropriate for an RN to

Perform. This step contains five concepts to guide the nurse to an answer. These include whether the act was:

1) taught in a basic nursing education program;

2) included in a national nursing organization’s standards of practice;

3) supported by nursing literature and research;

4) appropriately established policy and procedure is in place in the employing facility and;

5) addressed by a Nebraska Board of Nursing advisory opinion. If the answer is “no” to any of these questions, then the act is prohibited.

However, if the answer is “yes,” the nurse must progress on to additional steps. While exploring these 5 questions to determine if abdominal gastrostomy tube replacement was within a nurse’s scope, she found the advisory opinions to be the most helpful “list” available. While nursing literature, research and national standards of practice are thorough and timely, they are time consuming and potentially expensive for the average nurse to locate, especially for those that are less comfortable with technology. In addition, they rarely contain a “list” of appropriate nursing acts that a nurse can conveniently locate.

Thus, our second nurse located the advisory opinions from the Board of Nursing on the RN/LPN homepage of the NDHHS website. Jackpot! Gastrostomy tube replacement is included in the list! The following is what was found on the website: “It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for licensed nurses to replace gastrostomy tubes, jejunostomy tubes and suprapubic catheters for those clients whose stoma conditions are stable and well established. LPNs must do so under the direction of a licensed practitioner or RN. The decision to provide tube replacement should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.

Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.” After reviewing the opinion, it is the responsibility of the nurse to perform a selfassessment of knowledge and competence to perform the skill.

After navigating the website and the Decision Tree, the Decision Tree was found to be a helpful tool in determining if gastrostomy tube replacement was within the scope of practice for a Nebraska nurse.

As technology improves and advancements are made, it is obviously more prudent to have a Decision Tree and Advisory Opinions than “a list.” These tools allow nursing professionals to refer back to those entities that practice within the current health care environment and provide direction for the Nursing Scope of Practice. The Decision Tree is also an incentive to become more technologically savvy, as researching the other options outside of the Advisory Opinions require more investigation in defining the Nursing Scope of Practice.

Happy Navigating!