It is a weeknight shift at a 2000 bed male medium custody correctional facility. The health care staff on duty consists of a registered nurse (RN) who is “in charge” of the shift, three licensed practical nurses (LPN) and a clerk. The ten patients in the infirmary upstairs are cared for by a registered nurse, an LPN and a nursing aide. A medical emergency is called following an altercation between two inmates and the assigned LPN responds to the housing unit. The LPN determines that the men involved are okay and each is taken to segregation. Later one of the men is found unresponsive in his segregation cell. The LPN calls the on-call physician who orders the inmate transported by emergency vehicle to the local hospital where he dies later of a head injury sustained during the alteration.
Were staff appropriately assigned and supervised on this shift? If the charge nurse asked your opinion about how the shift was managed what comments or advice would you offer? The nursing staff at the facility were so motivated by the experience that the “after action” review included consideration of the state nurse practice act. Nurse staffing and assignment practices at the institution were changed as a result.
Ambiguity in the scope of practice for practical or vocational nurses and unlicensed assistive personnel (UAP) as well as their supervision in patient care are among the most significant challenges of correctional nursing practice. This issue was first identified last spring when nurses discussed the draft revisions to the Corrections Nursing: Scope and Standards of Practice to be published by American Nurses Association in 2014. The problem was discussed more extensively at the National Conference on Correctional Health Care in October 2012. Correctional nurses are not alone in these concerns. The National Council of State Boards of Nursing, Inc. has documented wide variation among state practice acts and among employers in the scope of practice of vocational or practical nurses (2005).
A tragic patient outcome like the one described here can be avoided with attention to scope of practice, clear assignment and delegation and good communication between personnel. The following are concrete steps that correctional nurses can take to begin to clarify and address concerns about patient safety related to the scope of practice of practical or vocational nurses as well as unlicensed assistive personnel.
1. Recognize that other personnel are necessary to achieve good patient outcomes. Correctional nurses are responsible for managing the health care of individuals who are incarcerated. To do so nurses assign, direct and supervise others to ensure that appropriate, timely care is delivered as planned. These personnel may include other registered nurses, practical or vocational nurses, and unlicensed assistive personnel. The plan for delivery of care may also include emergency medical technicians and correctional staff. In hospice or palliative care programs inmate caregivers may be included as well. The support of these personnel enables the registered nurse to attend to more patients with complex care needs. The registered nurse retains accountability for patient outcomes even when specific tasks of care delivery are the responsibility of others.
2. Be familiar with the scope of practice and regulations for registered nurses in the state where you are practicing. Correctional systems are not operated as health care organizations. Registered nurses must ensure that their practice is within the parameters allowed by state regulation because the correctional organization may be uninformed or naïve about the appropriate role or practice limitations of various health care personnel. Also these regulations change so nurses should review the state practice act annually. Contact information for state boards is obtained at https://www.ncsbn.org/contactbon.htm.
3. Be familiar with the scope of practice and regulations of other personnel relied upon to deliver patient care in the setting. In some states the nurse practice act also describes the scope of practice for practical or vocational nurses. It may also describe how and under what circumstances patient care can be provided by certified or unlicensed personnel. If not included in the nurse practice act, find and review other relevant information that defines the scope of practice for each of these types of health care providers allowed by state law or regulation. The registered nurse needs this information to appropriately assign or delegate tasks to others.
4. Review the job description, policies, procedures and other written directives at your facility that delineate the roles and activities to be performed by health care personnel in the delivery of patient care. This review is done to ensure that written directives of the agency are consistent with the state’s practice regulations and to identify more specifically how the nurse assigns, directs and supervises the delivery of patient care. Any inconsistencies between the employer’s expectations and state law should be identified and clarified through the nursing chain of command.
Chapter 17 in the Essentials of Correctional Nursing describes the role of nurses in supervising and managing the delivery of patient care in the correctional setting and provides a case example for further discussion. Order your copy directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.
General guidelines published by the National Council of State Boards of Nursing (1997) for the types of activities that can be performed by LPN/LVNs or UAPs include those which:
- frequently reoccur in the daily care of a patient or group of patients
- do not require the exercise of nursing judgment
- do not involve complex or multidimensional nursing process
- the results are predictable or carry minimal risk
- use a standardized and unchanging procedure.
Do you have concerns about scope of practice and the role of LPN/LVNs or UAP in your work setting? Share your thoughts in the comments section of this post.
National Council of State Boards of Nursing. (2005) Practical Nurse Scope of Practice White Paper. Retrieved December 26, 2012 from https://www.ncsbn.org/Final_11_05_Practical_Nurse_Scope_Practice_White_Paper.pdf
National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf
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