Laws are Not the Only Barriers to Scope of Practice
By Kristine M. Gebbie, DrPH, RN, Adjunct Professor, Flinders University School of Nursing and Midwifery, Adelaide, South Australia
The term, "scope of practice," is primarily linked to the legal definition of a profession in the statutes or regulations that define the profession and the niche it fills in the array of health practitioners. As such, the limits (or opportunities) presented by legal language is of primary importance to individuals and organizations considering exactly what a nurse, a physician, a dentist, a veterinarian, a naturopath or a physical therapist can be expected or allowed to do generally. However, the many decisions made by institutions in designing credentialing standards, position descriptions or practice policies may be of even greater importance on a day to day basis.
The research brief on nurse-managed health centers published on the Future of Nursing website1 puts the issue of credentialing into perspective. The authors identify the reluctance of managed care organizations to credential nurse practitioners as providers of primary care, despite the research literature supporting such decisions. Nearly half of responding organizations (47%) do not allow employed nurse practitioners the full legal scope of primary care practice that could benefit both patients and the organization. That credentialing is strongly influenced by geography and history is also evident, for example, in the number of U.S. institutions that limit the role of nurse midwives, while in many other parts of the globe they are readily credentialed and provide an enormous amount of obstetric care.
A further limitation may be imposed by employing organizations in the specifics of position descriptions (PDs) setting out what the employees in a given class or range are being hired to do.
One observed limitation on nursing practice is the socialized hesitation of many nurses to use critical thinking and decision-making to assure that patients entrusted to them are given the highest possible level of nursing care. Unless PDs reference the role of professional decision-making and use of evidence-based practice as expected behaviors and routinely evaluate these in performance reviews, there is no assurance that professional nurses will be as concerned about keeping current with the literature, developing critical peer review processes and carrying out identified best practices as they are with documentation and time-keeping (both of which are usually mentioned in PDs).
The ubiquitous policy and procedure manual, whether hard copy or electronic, is a further organizational barrier to the full scope of practice. Institutions should write down what is expected of staff under a range of circumstances, or when confronted by a specific need. Without a policy on ordering of medications, there could be chaos among prescribers, dispensers, distributors and documenters of drugs and dosages desired, used, and recorded. But policies are often written in the aftermath of a circumstance in which someone displayed poor judgment and caused a problem for a patient or for other staff. The organizational impulse in such circumstances is to become overly prescriptive, and to limit either the range of individuals who can perform a given function, or the range of choices available to those involved. It was organizational policy (as I understand it) that kept physicians administering injectible medications as being too complex until the time involved in round-the-clock antibiotic injections made it efficient to share the workload.
Self-imposed limits are at least as important as those presented by any organizational barriers. Comparisons of physician and nurse scope of practice2, often highlight MD roles that RNs do or do not take on, with no discussion of roles reserved for RN expertise. If nursing continues to define itself in large measure by what it shares with physicians, and what physicians can do that nurses usually cannot, it is extremely unlikely that patients and their families will come to understand that nursing and medicine are two complementary professions with a great deal in common, but with each having some characteristics not shared with the other.
Making the case that a nurse practitioner is as good as a physician without suggesting that there may be some nursing value added to the process of medical diagnosing and prescribing continues the message that a nurse is a bargain basement substitute for a physician rather than an essential member of the multi-disciplinary team.
1 Kovner C, Walani S. 2010. Nurse Managed Health Centers (NMHCs). Accessed 28 June 2011 at http://thefutureofnursing.org/sites/default/files/Research%20Brief-Nurse%20Managed%20Health%20Centers.pdf
2 Djukic M, Kovner C. 2010. Overlap of Registered Nurses and Physician Practice: Implications for U.S. Health Care Reform. Policy, Politics, & Nursing Practice 11(1): 13-22