Nurses Practice Beyond Their Scope — And It’s Not a Bad Thing

A very good, if obvious, idea on the use of RNs: nurses should be used to the full extent of their abilities. From the Toronto Star (and kudos to the paper for their Nursing Week insert in Saturday’s edition):

“The bottom line is that we’re wasting valuable resources with our RNs,” says Doris Grinspun, the Registered Nurses’ Association of Ontario’s chief executive officer. “European countries like the U.K. have been using RNs to their full capacity for years. It will be a missed opportunity for the public, taxpayers and patients if we don’t move to full utilization of our nurses.”
[Grinspun] wants the province to recognize the education and expertise of registered nurses, and to agree that they could be doing more within the scope of their practice, like diagnosing patients, ordering diagnostic and lab tests, conducting pelvic exams and prescribing medications.
Though the mandate of Ontario’s action plan for health care is to find ways to maximize the system, full utilization of care providers isn’t possible until the government revamps policies about who can bill for certain medical procedures. “We should be using nurses and all health-care providers to open access, increase the timeliness and quality of care and to contain cost,” she says. “But if a nurse does a pap smear, the doctor doesn’t get paid. If a nurse diagnoses a child’s ear infection and prescribes antibiotics, the physician doesn’t get paid. I go berserk when I see doctors taking blood pressure,” she says. “Nurses have the training to free up a doctor’s time in primary-care settings so she can focus on more complex situations.” Plus, the move to grant registered nurses more autonomy on the job would lower the waiting times for patients to be seen, meaning there will be fewer patients showing up at walk-in clinics and emergency rooms.

Not exceeding their scope of practice

The (somewhat) amusing thing about this idea is that nurses (or least those working in in high acuity areas like ICUs or Emergency Departments) already do all much of this in an highly unsanctioned, unregulated and unofficial way. Let me provide a simple example. Suppose I am triaging an exceedingly anxious patient with chest pain, and decide the patient requires an ECG — which incidentally I can order under medical directives. I explain the test to the patient. I tell her ECGs measure the pattern of electrical activity in the heart and therefore can show dysfunction. I place the electrodes across her chest and limbs, and carry out the test. The printout shows a patient in a regular sinus rhythm with no acute abnormalities.

Do I tell my agitated patient, whose anxiety is growing by the second, that (A) the ECG shows her heart is performing in a normal way and that we need to do some blood tests to confirm everything is okay, or (B) that the physician will discuss with her the results of the ECG when he sees her — which might be in a couple of hours?

When I was a new nurse, some years ago and being a good, diligent practitioner, I would have told this patient (B). This was not to dog my responsibilities or pass off work to the physician. (B), in fact, is the correct answer. Interpreting a test for a patient is considered a form of diagnosis, and in Ontario and most jurisdictions, making and communicating a diagnosis is considered the exclusive preserve of nurse practitioners and physicians.

But this is the deal. I have been educated how to interpret ECGs. I know how to tell atrial fibrillation from SVT from sinus tachycardia. I know what ischemia looks like, and I can spot ST elevations in a steam bath. More importantly I have the judgement to recognize the borderline cases and defer to the physician. Additionally, it seems to me, cruelty, indifference and bad nursing can be defined by a nurse telling a patient — especially one that is anxious —  that she needs to wait to speak to the physician about her ECG because of “the rules.”*

I am not for stupidity in the form of thoughtless adherence to regulation. I am not for cruelty either. So I decided a long time ago, that on balance, it was altogether better for the patient to have this information, rather than sit in the waiting room in a state of high anxiety. Even if my professional regulatory body has officially determined I can’t because technically it is beyond my scope of practice.

And so it goes. Nurses quietly and unofficially violate the scope of practice all the time. We push the envelope. We add blood work we think the physicians have missed. We slip in chest films because we know they need to be done. We order ECGs on patients we don’t like the look of.  We review lab results with patients. We cajole specialists into “having a peek” at a patient if we are worried about them. We tell patients — sometimes in very circular language, to avoid the damning “communicating a diagnosis” — what really is going on.

Why do we do it? Sometimes we know physicians will support us. Sometimes it’s to avoid difficult conversations with physicians, or because physicians won’t listen to the opinion of a mere nurse. (One physician I know of absolutely refuses to order serum lactates on obviously septic patients, because a positive result means she needs to follow a complicated sepsis protocol — even though the literature is pretty clear that early and aggressive intervention in sepsis saves lives.) Bottom line: we do it in the interests of the patient.

Should nurses be permitted to utilize their full knowledge and skills? Absolutely. It’s better for patient care and better for nursing work life. And also we need to formally regulate what nurses do already, to protect nurses themselves.


*The College of Nurses of Ontario, my professional regulatory body, would probably, and unrealistically suggest the alternative of getting the physician to speak to the patient immediately after doing the ECG as the “proper” course of action. But think about it this way: my ED probably does 30 ECGs (if not more) in the course of a 12-hour shift; if it takes a physician 5 minutes to discuss the results with a patient, then 30 x 5 minutes = 150 minutes = 2.5 hours.  That’s a pretty big chunk of time, and in a busy department, is not going to happen.  And that’s if you could get the physician to come out to triage to see the patients to begin with. It is simply not good use of his time and is completely unnecessary. Which rather demonstrates the point of the article quoted above.

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  1. #1 by Benoit on Monday 07 May 2012 - 1704

    As a patient with cancer, who has been to the hospital and the ER countless times – not to mention who has undergone tests and awaited results – countless times since 2006, I could not agree more with you on this topic. Whether it’s in the ER or at home, waiting for test results has always been a major cause of stress for me: new mets or not? With incurable kidney cancer, the answer may well be «I’ll live some more» or «I’ll die». So waiting for days, and more often weeks, for a doctor to give me the results is truly hell. Fortunately for me, sometimes, some nurses did tell me the results, at times good, at times bad. Either way, the stress was over. I had to get in my «swallow the news and get ready for another battle» or «Thank you God, I can enjoy more of this breather with no progression».

    Over the years, I’ve basically gotten to categorizing the nurses I’ve dealt with on this issue. First, the ones who fully understand what I feel and do what they can to make it easier; second, those who understand, but adhere to the rules because it could indeed mean their job if they talk; the clueless ones, like one who told me «Just wait. It’s only results, so it won’t change anything».

    Fortunately, the latter were few and far in-between, which shows just how dedicated most nurses are.

    • #2 by torontoemerg on Tuesday 08 May 2012 - 0907

      “Either way, the stress was over. I had to get in my «swallow the news and get ready for another battle» or «Thank you God, I can enjoy more of this breather with no progression».”

      Thanks for your comment and best wishes for good health. What if the news is more complicated than the RN feels competent to discuss?

  2. #3 by jeanhill on Tuesday 08 May 2012 - 1632

    A friend of mine nursed in a rural outpost facility where it was often only 2 nurses on staff and a physician could be called in if necessary. She was taught how and performed most of the suturing on patients coming in with uncomplicated lacerations. Think of how this might alleviate some of the time by physicians spent suturing, not to mention the nurses are typically providing health teaching regarding sutures and wounds/Tetanus immunizations after the suturing is completed anyways. I personally find in the ED nurses are waiting for the physician to finish suturing so they can complete the patint care. With the nurse at the bedside doing it allows his might allow the physician to see the more critical patients. That being said, nurse staffing ratios may have to facilitate the increased responsibilities and consider more time at the bedside. I question whether physicians would permit added responsibilities when it comes to their billing and what they would no longer be able to bill for.

    • #4 by jeanhill on Tuesday 08 May 2012 - 1634

      *with the nurse at the bedside this might allow….
      Excuse my poor typing please.

  3. #5 by CC on Friday 11 May 2012 - 0602

    All I can say is, it’s good you don’t live in Arizona. The hospital, MD and your own nursing professional body would hang you out to dry if something happened that an MD didn’t like. Sad, really – because as RNs, we are worth way more than that.

  4. #6 by suki on Friday 11 May 2012 - 1205

    What I find interesting and strange is how so many M.A.’s can and do diagnose in doctor’s offices today. I was going to have a surgery done (about 1year ago) and the surgeon didn’t even care to hear me(the patient) history. I have a history of a cardiac murmur, frequent pneumonias and heavy family history of M.I.’s/strokes. I had to push to get him to do some “work-up” due to the above (also my age should have been a clue) His office did a 12 Lead which the 25 year old M.A. read! Yes, the M.A. read it!!! Well since it is a doctor’s office an M.A. can do pretty much what ever the doctor allows them to do. I said, ” I need to get clearance from a pulmonary doc and visit the cardiologist first.” I then found out my B/P was too high, had now 3 murmurs and a pneumonia in place. I canceled the surgery with that doctor. Now leary of having any surgery done in Arizona. I find doctors to be just plain greedy and NOT listening to the patient and their concerns. The difference with the M.A.’s doing the doctors work is the doctor still gets paid as if he did it. Doctors like it that way. Now if an RN were to do that in Arizona………………..kiss your license goodbye. What is wrong with this picture?

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