Scope of Practice
Are registered nurses and midwives required by NMBI to double-check medications as part of their role in administering medications?
Firstly, it is appropriate to clarify what is meant by double-checking. An independent, double check of any medicines is termed independent verification. The nurse or midwife conducts their own calculation of the medicines and then compares with a colleague.
It is recognised that there are circumstances in care settings where the nurse or midwife is not working alongside other nurses or midwives – for example, working in the community, residential care units or on night duty. Double-checking the administration of medicines is not a statutory requirement. You may consider asking another nurse or midwife colleague to double-check a medicine if you determine that assistance is needed.
For patient safety and risk management purposes, health service providers may have a policy for independent verification of medicines, particularly for those that are considered high-alert (such as insulin, heparin and chemotherapy) or that require complex calculations in preparation for administration.
Are there any other factors that need to be considered in improving the standards of recording keeping?
You should consider including a review of local guidelines and policy on clinical record keeping as part of the audit process. You should discuss with your Director of Nursing a process and plan for examining and improving nursing staff documentation.
As a nurse with concerns about a request by my line manager to be redeployed to another ward, how should I go about exploring those concerns with my manager?
You can raise the following points for exploring the concerns you have with your manager (and any other relevant individuals) about safe professional practice caring for patients in a different environment from your current practice setting.
Assessment of your own learning needs for the competencies required for caring for patients in the particular setting you are asked to work in. The Standards and Requirements of the Nurse Education Programmes may be a good starting point to examine specific nursing competencies and knowledge relating to the various nursing divisions of the Register.
Organisational and nursing supports that you can use for developing the competencies to provide safe care. These supports may include professional development opportunities such as the nursing practice development department, Centre of Nurse Education, NMPDU and the organisation and specific patient units Policies, Procedures, Protocols and Guidelines (PPPGs). Ask about the resources and availability of the nursing staff and other health care professionals to assist you in assessing, planning, providing and evaluating the care specific to the needs of the patient population. They may include other members of the healthcare team, such as ANPs, CNSs, and medical staff.
Appropriate review and assessment of the patient(s) for planning care which addresses the general and specific health needs of patients. This should be a multidisciplinary approach referring to the various specialities as identified.
Establishment of communication structures and processes between staff and management to regularly review and discuss changes in practice and nursing care responsibilities within the work environment and specific patient units. The opportunities for orientation, preceptorship and peer support are also important to explore when you transition to a different practice environment.
Reference to national standards established by the HSE, HIQA or other statutory bodies. There may be particular standards that may direct care requirements and staff competencies.
As a public health nurse, I usually work on my own and have to rely on clients or family members to check medication with us. I have concerns about patients who receive drugs through a syringe driver, especially MDA Schedule 2 controlled drugs. Are public health nurses supposed to have two nurses with us when dealing with these drugs?
There are a number of key points to consider in addressing your concern. Does your health service provider have a medicine management policy that includes the management of controlled drugs? If so it should be used in association with current medicines legislation and the NMBI’s guidance on medicine management to guide your practice.
NMBI acknowledges that local need may dictate specific Policies, Procedures Protocols and Guidelines(PPPGs) authorising the practices of individuals involved with medicines. The local health service provider policy may require two persons to conduct the administration of MDA drugs. The checking, preparation, administration or destruction of these drugs by two individuals may also be mandated for in the policy. However there is no legal requirement for controlled drugs to be checked and/or administered by two individuals.
In your situation, in the community, it may be apt for you to ask the client (if appropriate) or a family member to witness the checking of the prescribed medication. Clear and direct communication with the client and their family about your role and responsibilities for medicine management should be undertaken at the initial stage of caring for the individual.
If you identify concerns about medicine practices including MDA use, either from your point of view, the client or family it may be helpful to organise a team meeting to openly talk about these issues. Maintaining good clinical records are also essential in providing care safely and effectively. You should read the NMBI’s guidance for recording clinical practice.
As children’s nurses in a busy paediatric unit, we are constantly receiving telephone queries from concerned parents and caregivers about the illness of their infants and children. We are concerned about the basis on which we give advice to the parents by telephone.
The concepts of accountability, autonomy and competency within the Scope of Nursing and Midwifery Practice Framework can be used to guide you in determining your scope of practice in relation to telephone inquiries.
You must practice within the limit of your own competence and assist parents/clients to make informed decisions. For each individual situation you will need to consider the overall benefit and best interests of the infant's or child's care and safety.
If you are not competent to carry out a particular role or function, then to do so would be outside your scope of practice and would be in breach of the Code of Professional Conduct and Ethics. When a nurse or midwife makes a judgement that they are competent to carry out a particular role or function then they are fully accountable for that decision and any subsequent actions.
The development of polices and protocols to advise and support the staff should be taken at local level taking cognisance of the Code and the Scope Framework. The HSE resources on the development of policies, procedures, protocols and guidelines (PPPGs) may also be of benefit and inform in the development of local policies and protocols.
Another resource is the National Clinical Effectiveness Committee’s Standards for Clinical Practice Guidance
Can I catheterise male patients? I have never done this before and it was not part of my nurse training.
You must make a judgement about whether you are competent to carry out this function. Competence is understood as the “attainment of knowledge, intellectual capacities, practice skills, integrity and professional and ethical values required for safe, accountable and effective practice as a registered nurse or registered midwife.” For further definitions, visit our glossary of terms.
For many nurses catheterising male patients is an expansion of practice and this must occur within the context of the definitions of nursing and midwifery. It is recommended that a local policy and a clinical guideline be devised and put in place in the clinical area.
An evidence-based policy and guideline, which also addresses patient consent, needs to be developed. Due to the nature of the practice, there needs to be interdisciplinary involvement in terms of developing the policy/guideline and the training and assessment process. Appropriate education, training and competence assessment supports for the registered nurse are critical in the clinical area.
The individual nurse is accountable for decisions they make in determining their scope of practice. This includes decisions to expand or not to expand their practice. For more information:
Can I take a verbal or telephone order from a doctor particularly in an emergency situation?
The only acceptable time a verbal or telephone order should be taken from a doctor is in an emergency situation. Accepting a verbal or telephone order should not be considered a substitute for a comprehensive medication policy or protocol for routine medication management. The overall benefit to the patient and ensuring their safety should be prioritised in these situations.
The key considerations of responsibility, accountability, autonomy and competency should guide the individual nurse or midwife in determining their own scope of practice relating to emergency situations. These are outlined in the Scope of Nursing and Midwifery Practice Framework.
A registered nurse or midwife utilising the framework and the principles of the Code of Professional Conduct and Ethics in their provision of care would be considered to be practising in a safe and competent manner. You should also refer to our Guidance on Medication Management (ABA, 2007).
The development of policies and protocols to support verbal or telephone orders in emergency situations should be undertaken at a local organisational level which reflects this guidance.
I am a nurse working for a telephone triage service. I am not a midwife. Is it possible to provide antenatal and post-natal advice over the phone?
The provision of antenatal and post-natal advice (in person or over the phone) is within the scope of practice of a midwife. A nurse who is not a registered midwife is practicing outside their scope if providing professional advice in such matters. In such situations you should refer the woman to another professional such as a midwife or to a GP.
All registered nurses and midwives must practice within the limit of their own ompetence. Interpersonal relationships is one of the five domains of competence identified by the Nursing and Midwifery Board of Ireland (NMBI). An indicator for this domain of competence is that nurses must assist clients to make informed decisions.
This is fundamental to the role as a telephone triage nurse. However, the freedom for you to act in accordance with you professional judgement in relation to areas within your scope of practice brings with it the principle consequence of accountability for your decisions and actions.
The provision of antenatal and post-natal care is identified within the scope of midwifery practice referred to within the Practice Standards for Midwives.
For more information:
I am a nurse working in a nursing home. I am the only staff nurse in a ward. Administering medication is difficult for me to manage and I am concerned that residents are not receiving their medicines on time. Can I delegate the task of administering medicines to a healthcare assistant?
As a registered nurse, you are accountable to NMBI for your professional practice, which includes the safe administration of medications. Each situation should be reviewed individually as it arises. It is also important that you know what your employer's policy is for the staff responsibilities nurses and non-nurses - in the administration of medications.
The resident's best interests and safety should be the primary factors in making your decision while the nursing care plan for the resident should help to determine the assistance they require.
When considering delegation of this activity, you should ensure that the care assistant is an appropriate person to delegate to. You must consider the level of experience and competence of this person before assigning this task:
- Has the care assistant the necessary skill to administer the medication to the individual resident/patient?
- Are they familiar with the resident and aware of any special needs in assisting them to take the medication?
- Has the care assistant been informed of their responsibilities in taking on this task? For example, does the care assistant need to report any information back to you after completing the task? If so, this should be reviewed with the care assistant prior to the actual administration of the medication.
You as the registered nurse are responsible and accountable for ensuring that the delegation of medication administration is appropriate in each particular situation.
The NMBI guidance on delegation is covered in Principle 5 Collaboration with others of Code of Professional Conduct and Ethics. Also, the Scope of Nursing and Midwifery Practice Framework also contains detailed guidance on the issue of delegation and supervision. Working through the Scope of Nursing and Midwifery Practice Flowchart should assist you in considering whether or not you should delegate this activity of medication administration to a healthcare assistant in a specific and defined circumstance.
I am a Registered General Nurse (RGN). My employer would like me to be deployed to the Children’s Ward in the hospital on an interim basis. However I have concerns about this because I am not a Registered Children’s Nurse. What is NMBI’s advice?
NMBI as the regulator does not control how staff are deployed or utilised in health care settings.
It is the responsibility of your health service employer to determine the criteria such as the competencies, skills, knowledge and experience required to nurse in a particular setting. This may include establishing what division(s) of the Register or Nurses and Midwives a nurse must be registered with NMBI to work in that particular area. We do not dictate that a nurse is registered in a particular division for him or her to work in a specific practice setting or care for a group of patients.
The quality of practice section of our Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives and the competence section of the Scope of Nursing and Midwifery Practice Framework aim to support and provide best practice for all nurses and midwives which will ensure protection of the public.
If you are being asked to provide nursing care in a different practice environment, you should review the key considerations section in the Scope Framework.
I am a registered nurse (RNID) in an Intellectual Disability Service and I work in a community residential facility. Am I allowed to provide first aid in this residential setting?
NMBI advises that you review the Scope of Nursing and Midwifery Practice Framework and accompanying flowchart to consider your role in providing first aid in your community residential setting. It is critical you have the competencies needed to give first aid.
In particular, you need to review the Considerations for determining your scope of practice section. This says that you need to ensure you have the knowledge and skills to perform first aid safely and your employer supports this activity in the facility. NMBI supports the development and implementation of evidence based Policies, Procedures Protocols and Guidelines (PPPGs) to support nursing staff in meeting the interests of patients and residents who require first aid.
In addition to your employer’s direction you and your line manager may want to examine health and safety legislation which is available on this section of the Health and Safety Authority’s (HSA) website. The HSA website also provides guidance specific to first aid provision. These resources should be used alongside applying the values and standards of conduct detailed in the Code and Scope guidance. They can support you to explore any future role and responsibility for providing first aid in emergency situations in your care facility.
I was recently appointed as a CNM1 in a small nursing home that receives patients from the regional hospital. Two nurses just joined our staff from this hospital who have suggested our documentation of nursing care for residents need to be improved. Can you advise how this might be approached ?
I work as a nurse in a nursing home which is introducing the practice of intravenous medication administration for residents. The majority of these IV medications are antibiotics. I am concerned about the safety aspect of this practice particularly possible adverse reaction and anaphylactic shock. What kind of resources should I refer to?
There are a number of resources NMBI can direct you to regarding developments in practice and best practice guidelines in relation to intravenous medication administration and therapy. Firstly NMBI has published guidance on medicine management Guidance to Nurses and Midwives on Medication Management which provides guidance for nurses and midwives. The accompanying eLearning programme which is available on HSELand.ie should also be reviewed. HSELand.ie also lists courses on peripheral intravenous cannulation.
Each nurse or midwife should take appropriate steps to develop and maintain competence with regard to all aspects of medicine management, ensuring that her/his knowledge skills and clinical practice are up to date. This point is significant for you in view of your nursing home initiating intravenous medication administration as an expanded service for residents. The Scope of Nursing and Midwifery Practice Framework is also a useful tool for you in considering your professional responsibilities.
Assistance and support from your employer should be sought. This should include emergency management of anaphylaxis and adverse events associated with IV therapy.
Also, there is an international speciality organisation for nurses interested in IV therapy called the Infusion Nurses Society which has an Irish chapter.
I work as Nurse Practise Development Co-ordinator and support nursing staff taking on new procedures and responsibilities. Nurses often ask if they are “covered” to undertake these responsibilities. Apart from Scope of Nursing and Midwifery Practice Framework and the decision-making flowchart, are there other issues I should consider?
“Am I covered?” may have various meanings from one individual to another. You may find it helpful to explore with the nurse(s) what they actually mean when they use this phrase. You are building a good foundation by using the Scope Framework for discussing their concerns. As a nurse practise development coordinator you know individual decisions about scope of practise are complex so reviewing the Considerations and the Principles section is important.
The Scope Framework’s resources can help you direct the nursing staff to explore the particular issues about “coverage”. These include determining whether there is any legislation prohibiting the proposed role or activity. All relevant legislation and statutory instruments legislation can be accessed on the Irish statute book website.
You should refer to the HSE website and particularly the Policies, Procedures, Protocols and Guidelines (PPPGs) section to determine if precedence has been set regarding the proposed activity. The Scope flowchart can help staff pinpoint their concerns and act on them. Another avenue to explore may be your organisation’s risk management and quality and safety resources.
The topic of indemnity can also form part of the discussion about concerns of “coverage”. The Professional responsibility and accountability section of our Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives gives advice on indemnity.
The unit that I work in has no phlebotomy service. My line manager asked me to provide this service to patients. Am I covered to take blood?
Taking blood is generally considered within the scope of practice of a nurse or midwife who must be competent to do so. If a nurse has not developed or maintained competence in the area then to take blood would be outside their scope of practice. Your manager should not delegate this activity to you if they know you are not competent to perform phlebotomy.
In such a situation, you should take measures to develop or to update, your competence. This may require continuing professional development (CPD) within the organisation. Development of policies, procedures, protocols and guidelines (PPPGs) should be undertaken at a local level to ensure that such practice is evidence-based.
Nursing and midwifery practice should develop to meet the ever-changing needs of the population and the health service. Expanding the role of the nurse and midwife involves becoming competent, reflective practitioners, developing expertise and skills to meet the patient’s needs in a holistic manner.
For more information, read the Principles for Determining Scope section of the Scope.
What other bodies apart from NMBI should I refer to in relation to the use of abbreviations.
The HSE has published guidance in drawing up an approved list of abbreviations. This is included in a document Code of Practice for Healthcare Records Management document.
Internationally there is much guidance on the use of abbreviations within healthcare settings. The Institute for Safe Medication Practices (ISMP) compiled a list of more than 60 commonly used abbreviations, symbols, and dose designations that have been implicated in medication errors. The Joint Commission on Accreditation of Healthcare Organisations (JCAHO) is another useful resource.
ICAHO has conducted research finding the use of abbreviations in health care may be efficient, however this may be at the expense of patient safety by contributing to medication errors. In addition to publishing a list of approved abbreviations the JCAHO has published lists of approved and prohibited abbreviations.
Why is it so important to maintain a high standard for clinical records ?
There are several reasons:
1. To document nursing and midwifery care. At a minimum the clinical record should include:
- An accurate assessment of the person’s physical, psychological and social well-being, and whenever necessary, the views of family and carers in relation to that assessment
- Evidence in relation to the planning and provision of nursing care, and an evaluation of the care provided
2. To aid communication between the patient, the family and the health care team
3. To provide documentary evidence of the delivery of quality patient care.
In addition to the NMBI guidance it is critical that your organisation operates to any relevant recordkeeping and documentation standards from other relevant agencies. An example is HIQA’s National Quality Standards for Residential Care Settings for Older People in Ireland. This standards document addresses record keeping requirements including the details required of each resident. Another example is the Mental Health Commission.
Regular audit has been shown to improve the standard of record keeping in nursing and midwifery and hence the standard of patient care.