The decision-making framework provides a guide for nurses to follow to ensure that they continue to act within the scope of practice. The models contribute towards the regulation of the nursing practice. Some components of the model include the:
- Nursing’s Professional Scope of practice, the standard of practice, code of ethics, and specialty certification.
- Nurse Practice Act rules and regulations.
- Institutional Policies and Procedure
I worked as a wound care nurse in a hospital-owned wound care center. The team members worked within their scope of practice. For example, If I assessed a wound and the wound bed needs some debridement, I usually call the surgeon since surgical debridement is not within my scope of practice. Ethical responsibilities were seen as each staff carried out their role. “The ethical tradition is self-reflective, enduring and distinctive” (ANA, 2015). Ethics is very important as nurses work within their scope of practice and follow their standard of practice. For example, it was my responsibility to inform the right person first (surgeon) about a wound that needed debridement and also ensure that a follow-up appointment is scheduled. This helps with the continuity of quality care. When wound healing is not progressing, early detection can also help prevent it from becoming worse. In addition, we had weekly meetings where team members collaborate on difficult cases. The members include nurses, certified wound care nurses, a surgeon, a podiatrist, and a CHRN (Certified Hyperbaric RN). The aim was to ensure optimum patient outcomes. A lot of evidence-based practices are seen in the wound care setting. These practices enhance the quality outcome of patients such as the use of silver products to dress a wound or the use of synthetic skin grafts for diabetic ulcers. Special specific certifications and training are required to ensure that nurses are competent and able to provide safe care to patients. An example was when I was trained specifically on wound vac application. Whenever a wound vac is needed and ordered for a specific duration, I will apply it in line with the order. This example answers the “why”, “where” and “how” of nursing (Scope of Practice, Standard of practice, Specialty Certification).
The Nurse Practice Act (NPA), encourages a safe quality nursing practice for the benefit of the public. Delegations made were in line with the NPA requirement and the criteria for delegation were met. For example, the qualification of nurses, the safety of patients and the five rights of delegation were considered during delegation. For example, I have been delegated by my manager to set up an ultrasonic debrider for the doctor, but I have never been delegated to use it because it is not within my scope of practice and I am not qualified to use it (Nurse Practice Act & Rules).
For proper protection, the organizational policy there was to treat all wounds as if they were infectious and could get infected. Standard precautions were always followed including gowns and shields in cases that could involve splashes. All non-disposable equipment used was sterilized after each use. These protocols were to protect the staff and patients from any infection that could arise. Also, we followed a protocol that involved a wound culture for every new patient. This helped a lot because it helped with early detection of infection and early treatment since infection is a major cause that can inhibit wound healing. (Institutional Policies and Procedures).
When all team members embark on their respective roles in line with their various scope of practice, there was progress towards achieving a set goal. I was also determined to do my part in ensuring quality care. I was able to advocate for patients and achieved the maximum outcome for the clients within my scope of practice. It encouraged me and gave me job satisfaction to see that critical wounds and traumatic wounds eventually healed after a joint team effort. As I progress in nursing, I am determined to practice professionally within my scope of practice and contribute towards a safe and positive patient outcome (Self Determination).
American Nurses Association. (2015). Nursing : Scope and Standards of Practice: Vol. 3rd edition. American Nurses Association.
Advisory Opinion looks into a specific practice to determine if it is within the scope of practice of nursing or not. It analyzes a specific nursing practice question and may or may not give recommendations. The value attached to an advisory opinion differs from one state board of nursing to another. According to the Arizona State Board of Nursing, for instance, they describe advisory opinion as an “interpretation by the Board of what the law requires” and they see it as “more than a recommendation”. On the other hand, the Department of Human Services Nebraska considers their advisory opinion as “informational only and are nonbinding”. Therefore, it is important that registered nurses practicing in a jurisdiction are aware of their advisory opinion and the rules or restriction surrounding them. Another example of an advisory opinion is the administration of ketamine which will be compared between Arizona and South Carolina. In Arizona, registered nurses without CRNA (Certified Registered Nurse Anesthetist) cannot administer ketamine IV, or Intranasal bolus for the purpose of anesthesia or analgesia but can administer low dose ketamine for pain control, depression and sedation in line with their advisory opinion. For South Carolina, registered nurses can also administer low-dose ketamine but for specific diagnosis listed and not for sedation.
Arizona and South Carolina have some similarities in their advisory opinion regarding Ketamine administration which includes:
- Registered nurses in both states can administer low-dose ketamine following monitoring precautions.
- There must be frequent monitoring of patients such as frequent vital signs and the use of a sedation assessment scale.
- Both states are mentioned that registered nurses can administer minimally low-dose ketamine.
- Both states also mentioned that Ketamine is a controlled substance and therefore should be handled with precautions.
- Both states’ advisory opinions are not intended for anesthesia.
Some of the differences between the two states regarding ketamine administration include:
- In Arizona, health care professionals should have PALS and ACLS. This professional must be present from initiation till the end of the administration. Also, it is not within the scope of practice for non-CRNA registered nurses to administer ketamine bolus via IV or intranasal for analgesia or anesthesia. In South Carolina, it is within the scope of practice of a registered nurse to administer Ketamine IV push or continuous infusion for acute pain management and a list of other diagnoses. Other requirements include a physician order.
- Although South Carolina has established some precautions, they allow facilities to make some decisions. Such as deciding the education and competencies required for the nurses designated by the facility to perform this role. On the other hand, Arizona seems to be more specific in stating what they want and defining the limits for their nurses.
- In Arizona, standing orders or protocols are not used to adjust the infusion rate for low dose ketamine while in South Carolina, there can be an adjustment in line with the facility protocol but must be done under a physician’s supervision.
When advisory opinions are made, it requires competency on the part of the nurse for any nursing action performed. For example, if an advisory opinion states that registered nurses can administer naloxone in life-threatening opioid cases without an order. Even if it is not binding, it will still be the nurse’s responsibility to act competently and still be accountable for actions taken. The role of the regulatory agency focuses on making sure that the advisory opinions that are put out are adopted in line with the standard of practice. They also ensure that nurses are held accountable for their actions in the course of nursing practice.
Advisory Opinion Ketamine Administration. Arizona State Board of Nursing. (2020.). https://www.azbn.gov/scope-of-practice/advisory-opinions.
Nursing Advisory Opinions. Department of Health and Human Services, Nebraska. (n.d.). https://dhhs.ne.gov/licensure/Pages/Nursing-Advisory-Opinions.aspx.
Joint Advisory Opinion Issued by the South Carolina State Boards of Medical Examiners, Nursing and Pharmacy Regarding the Administration of Low Dose Ketamine Infusions in Hospital Settings, including Acute-Care, by Nurses. South Carolina-labor Licensing Regulation. (n.d.). https://llr.sc.gov/nurse/pdf/Low%20Dose%20Ketamine%20Joint%20Advisory%20Opinion%20Approved.
Nursing Practice Standards 1-6:
Standard 1 Assessment: Assessing my patients is usually the first thing I do. This helps me collect both objective and subjective data on my patient’s health situation. Sometimes I do a focused assessment depending on the issue. An example was when I cared for a patient with pneumonia. I did a focused assessment by auscultating the patient’s lungs to monitor the lungs sounds and I did her vital signs too. Another example of an assessment was when I found a resident on the floor. I had to first assess her breathing, level of consciousness, alertness, and vital signs.
Standard 2 Diagnosis: The analysis of the assessment obtained gives rise to a nursing diagnosis. For example, after assessing the patient’s alertness and level of consciousness of the patient that fell, the patient was at risk for fall-related to hypoglycemia as evidenced by dizziness. Another example of diagnosis was with a chemo patient receiving chemotherapy. The patient was exhausted and finding it difficult to cope with activities of daily living. After the assessment, a nursing diagnosis for activity intolerance was identified.
Standard 3 Outcome Identification: When a diagnosis is made, the expected outcome for the patient should be identified. For my patient who fell due to dizziness from hypoglycemia, the expected outcome will be a normal blood glucose level and no falls. Another example is identifying that the chemo patient will participate in activities of daily living without getting exhausted.
Standard 4 Planning: In planning, once the outcomes are identified, a plan on how to achieve them is made. For example, For my patient whose identified outcomes are to maintain normal blood sugar and no falls, a plan was made to monitor the blood sugar through finger sticks before every meal for a period of time. For the fall risk, a plan to implement fall precautions was made. Another example for the chemo patient was the plan for her to have assistance during her ADL’s and plan to re-enforce the teaching on the use of call bell when needed.
Standard 5 Implementation: The plan made for the patient under standard 4 was implemented. The interventions were carried out. Blood glucose monitoring was done and fall precautions were implemented for the period of time it was needed. Another example for the patient on chemotherapy was that assistance was provided when needed and to help with ADL’s
Standard 6 Evaluation: This standard emphasizes reviewing the outcome. The essence is to know if the identified outcome was achieved via the interventions or not. If they weren’t, then why? Any setbacks? For those patients, the plan made for them in standard 4 was effective in achieving their identified outcome during the plan period. The evaluations were done by observing, interacting with the patient, and reviewing charted information.
Professional Performance Standards 7-17:
Standard 7 Ethics: This includes the moral principle that is guiding an individual. In nursing, ethics is also a major aspect of the profession. Abiding by the professional code of ethics, conduct, and principle is important in nursing. Patients are respected and treated with kindness. The cultural values of patients are also respected without judgments. Ethics also helps me act professionally as an advocate for my patients, also knowing what is right and wrong is vital in delivering quality patient care.
Standard 8 Culturally Congruent Practice: Registered nurses should be open to care for all individuals regardless of their cultural beliefs and norms. Nurses should be non-judgmental but respect the values and beliefs of patients. An example is when a patient is dying, there could be some religious rites the patient and family could want to observe. Registered nurses should respect it when delivering care regardless of what the nurse’s beliefs are.
Standard 9 Communication & Standard 10 Collaboration: Standards 9 &10 oftentimes work together. Effective communication is needed by registered nurses when collaborating with other professional team members on a patient’s care. Communication has to be clear, specific, and sometimes with feedback. An example was when a care partner was delegated to do vital signs for specific patients and report back on their vital sign’s values. Also, that was a collaborative effort to monitor the blood pressure of those patients.
Standard 11 Leadership: Nurses should possess some leadership qualities and skills. This is because leadership is part of the nursing profession. An example is the position of a charge nurse who is making sure team members are completing their assigned duties and reporting back on the assignment. Also, a leader should be prompt in resolving issues that arise concerning patient care.
Standard 12 Education: Education helps nurses to acquire more knowledge and skill in their profession. This helps nurses to be more equipped and competent in delivering quality care to patients. Examples of avenues to acquire knowledge besides readings include training, seminars, continuous education program, and the BS program.
Standard 13 Evidence-based Practice and Research: This is important because it enables nurses to aim at the most effective care, based on evidence. Due to the changing medical situations and technology, researchers contribute to ensuring that evidence-based information is available for use to achieve positive patient outcomes.
Standard 14 Quality of Practice: This is a major responsibility of nurses. Nurses should provide quality nursing. Acquiring knowledge and skills enable nurses to practice competently within their scope of practice delivering quality nursing care to patients. An example is the use of critical thinking judgment and skill to know when to apply a focused assessment on a patient when needed to avoid delay in care.
Standard 15 Professional Practice Evaluation: This standard allows for nurses to self-assess their nursing practice and also evaluate others. This goes a long way in determining if things are going in the right direction or whether changes and adjustments are needed.
Standard 16 Resource Utilization: The appropriate use of available resources helps in achieving efficiency and quality on the job. Resource utilization also helps alleviate certain workloads off nurses, making them focus on more critical areas. For example, with staffing, if a registered nurse has a care partner assisting with vital signs, she can go ahead for an IV insertion with another patient.
Standard 17 Environmental Health: A healthy work environment is important in achieving a positive outcome that is sustained for both patients and healthcare professionals. An example is when a working environment is safe and free from environmental hazards, nurses can provide care safely to patients.