Can I Do That? Incorporating Scope and Standards of Practice Into Nursing Professional Development

Nurses who are new to progressive and critical care have a lot to take in during their first few months. They perform many nursing activities that they’ve never done. They work in a brand-new environment with unfamiliar people and develop new skills all the time.

Both new and experienced nurses in progressive and critical care are faced with situations where they are uncertain whether something they are asked to do is within their scope of practice. Even experienced nurses have questions related to scope and standards of nursing.

As an educator, you will get questions about specific situations. You know how challenging these questions can be. Fortunately, there are resources to help us determine the answers, and you’ll want to incorporate them into your professional development plans.

How Do I Know?

Here is one of the most common questions I receive at AACN: “Is this (medication, procedure and practice) within my scope of practice?” Because the answer to that question takes into account not just the scope and standards of practice but also must align with your state board of nursing, other regulations and hospital procedures, AACN rarely can definitively answer that complex question.

What the scope and standards offer is the guidance to evaluate your scope of practice, and your standards of both practice and professional performance. The appendix contains an Ask the Experts article titled “Scope of Practice.” Within that article is a decision model with four questions to help you decide if something is within your scope of practice.

1. Is this activity/role/task/procedure/intervention prohibited by your state’s nurse practice act, rules, declaratory rulings or other applicable law, or accreditation policy?
2. Does the activity/role/task/procedure/intervention meet criteria such as the following:
   • Congruent with national nursing standards
   • Consistent with current evidence-based practice
   • Consistent with policies and procedures approved by the employing facility
   • Appears in the nursing literature and research
   • Conforms to the practice of a “reasonable and prudent nurse in this situation or environment”
3. Do you possess the requisite knowledge, clinical skills, abilities and judgment to safely and effectively perform this activity/role/task/procedure/intervention based on your prelicensure educational program, postgraduate program or continuing education program? Is your education documented?
4. Are you prepared to accept accountability for the outcome of the activity/role/task/procedure/intervention, and are you competent to provide emergency care for the patient in the event of untoward outcomes due to the activity/role/task/procedure/intervention?

Using this exercise during orientation or ongoing education is a great way to incorporate the scope and standards into training.

Speaking up for Patient Safety

I was recently talking to a charge nurse who shared this scenario. The nurses learned that their hospital is going to buy new infusion pumps and have them programmed with standard titration orders, which the nurses won’t be allowed to bypass.

They were concerned that the pharmacist-programmed titration dose is larger than what they would consider a safe titration dose to increase in a single step for many patients. They wondered whether they could challenge the hospital pharmacists’ dose decision and how. Although it might not sound like it, these nurses were asking about whether challenging this decision is a role they should be taking and within their scope of practice.

The purpose of the “AACN Scope and Standards for Progressive and Critical Care Nursing Practice,” is to describe the practice of nurses who provide care to acute and critically ill patients. Scope of Practice defines the boundaries of the practitioner’s license. While Standards are authoritative statements that describe the level of care or performance common to the profession of nursing and are used to judge the quality of nursing practice. Scope and standards guide our actions and help us manage our practice along with the challenges we face in nursing.

In the titration dose dilemma, the AACN’s document scope and standards became their guiding light; “The scope of practice for nursing care of patients of all ages encompasses the dynamic interaction of the patient and family, the nurse and the environment where care is being provided, with a goal of ensuring optimal patient outcomes.” Standard 1 of professional performance states all nurses need to be involved in efforts to improve the quality of practice, patient safety and clinical outcomes. Ensuring optimal outcomes, patient safety and improving the quality of practice was their goal for raising the concern about standardization of orders for the new infusion pumps.

Working With Peers

Sometimes the questions you receive arise from challenging situations with peers. At a conference last year, I talked to nurses who were struggling to engage their colleagues in shared governance and performance improvement. They were also struggling with bullying of novice nurses. We discussed the standards of professional performance and how the standards might help them open a dialogue about improving the health of the work environment, engaging their colleagues in shared governance and putting an end to bullying.

There are 10 standards of professional performance in AACN’s document. I suggested two standards in particular to share with their colleagues as a starting point to guide these nurses in conversations about changes they wanted to see in their work environment:

When working with peers, finding a common purpose and working toward it is key for people to feel safe and develop trust. In this situation, improving nursing practice in their environment required these nurses to develop competence in these two standards. While all of us know that we need to have excellent clinical skills, these standards require us to develop equally excellent skills in communication and collaboration. Using these two standards as a starting point, the nurses supported their unit-based council and began addressing the elements that were contributing to an unhealthy work environment.

Taking Care of Yourself

Progressive and critical care nursing are demanding specialties. I’ve seen many new nurses and experienced nurses alike deal with ethical conflicts. One example is the vignette written on ethical accountability for patients about a nurse who intervened when a patient didn’t want to be intubated.

In the AACN’s scope and standards document, Standard 5 — Ethics, a section of this standard is titled “Ethical Obligations to Self.” As nurses, we are often selfless. We enter the profession with the intent of giving. Inclusion of this part of the standard requires us to be vigilant about the very difficult and necessary skills of self-awareness and self-care. Adding this to our professional development education plan for nurses is essential to their capacity to care for their patients. It also applies to us as educators in caring for our nurses.

Helpful Vignettes in the Scope and Standards

Using AACN’s scope and standards in professional development plans is helpful for keeping your staff up to speed on this great resource. In the current edition of the scope and standards, each standard of professional performance comes with at least one example to describe how the standard may be applied in practice. Use these examples as case studies with nurses to prompt a deeper discussion on situations they face.

Where there is ambiguity in our practice the scope and standards are an invaluable resource for defining the boundaries of progressive and critical care nursing practice and providing guidance for the standards of professional practice and performance. I know many of you have incorporated the scope and standards into your educational offerings and unit governance structures.

I would love to hear from you about how you have leveraged AACN’s scope and standards in your practice or with your unit.