LPN Suzanna is on duty at the county jail when Mr. Martin strikes his head on the top bunk metal frame. She is called to the pod, and after determining that Mr. Martin is stable with only a 3 cm laceration to the middle of his forehead, she brings him to the medical unit. After she cleans the wound and the bleeding is stopped with pressure, she notes that the wound is gaping. She calls the provider on-call, Dr. Smith, who tells her to “use the superglue” on Mr. Martin’s laceration. LPN Suzanna tells Dr. Smith that she has seen the procedure done many times, but she has not been formally trained on the application of Dermabond© and she has never done it herself. Dr. Smith tells her she is a great nurse and to go ahead and do it.
LPN Suzanna does the application and the wound heals without a problem.
LPN Suzanna is working in a state where the Nurse Practice Act does not allow LPNs to suture or provide any type of wound closure, although LPN Suzanna is not aware of her scope of practice in that state because she is there working under a multi-state license.
Did LPN Suzanna practice beyond her scope? Could she be reported to the Board of Nursing even though there was no negative outcome in Mr. Martin’s care? The answers are simple – yes, she did practice beyond her scope as an LPN and yes, she could be reported to the Board of Nursing, even with a successful intervention.
How did we determine this?
The Nurse Practice Act in each state determines the professional nursing activities of the LPNs, RNs and APRNs licensed in that state. It is typically authored by the state Board of Nursing and is enacted into law by the state legislature. In most states, the Nurse Practice Act is purposefully written broadly. The State Boards of Nursing define and interpret the state Nurse Practice Act, and monitor the nursing activities of the nurses in its state. Nursing activities reported to the State Board of Nursing often are the result of a negative patient outcome, but any instance of a nurse practicing beyond her/his scope of practice can result in an investigation by the Board. The State Board of Nursing may implement rules and regulations for its nurses that are stricter than those in the Nurse Practice Act, but it cannot expand or change the Nurse Practice Act itself. Any changes must be presented to and passed by the state legislature. All nurses are required to know the Nurse Practice Act in their state (and any state in which they are practicing) and practice accordingly. Not knowing these parameters is not an excuse for practicing beyond its standards.
The nurse’s scope of practice is also dictated by national accreditation standards, specialty nursing scope and standards of practice (such as the Correctional Nurse: Scope and Standards of Practice), and the policies and procedures of the employer. However, it is important to note that none of these documents can authorize the nurse to have an expanded role beyond that set forth by the state Nurse Practice Act. So, for example, if a policy of the healthcare company providing services at your facility allows LPNs to suture patients, but the Nurse Practice Act in your state prohibits this activity, then the policy should be changed to reflect the current legal parameter in the state. It is your responsibility as the licensed nurse to ensure that you are practicing within the requirements of the Nurse Practice Act and Board of Nursing in your state at all times.
To assist nurses, employers and patients, the National Council of State Boards of Nursing (NCSBN) has developed a Scope of Practice Decision-Making Framework to be used when determining whether a particular nursing activity is within the nurse’s scope of practice. In our next post, we will review the framework in more detail and discuss the implications of working under a multi-state license.
With regard to Suzanna’s specific actions, even without knowing if LPN practice in her state was prohibited from using the Dermabond©, she performed an act knowing that she was not trained properly and had not demonstrated competence in the activity. This violated the Nurse Practice Act.
Do you know your state Nurse Practice Act and Board of Nursing rules and regulations? How do you handle being asked to perform a nursing act that you are not sure is allowed by your Nurse Practice Act? Please share your experiences in our comments section.
Douglas Manley says
Hi Lori,
I read your articles quite frequently and really do enjoy reading them because it provides me with great information on how I should expect nurses to perform while in their care. I’m not a nurse nor do I work in the medical profession however, I do appreciate the dedication and hard work everyone goes through in medical, especially since Covid. It appears to me there’s a very high volume of shortages in nurses which causes longer work hours and more stress on our medical providers. I hope this changes soon.
I want to share with you, and your readers, of an incident that happened to me in 2022, into 2023, about 15 months, when I was an inmate at a prison in Illinois.
First let me start by mentioning that I was diagnosed with a collapsed bladder due to becoming overly stretch where the muscles were weak and prevented me from expelling urine without the use of an intermittent urinary catheter. I have now used a catheter at least 5 times a day, for over 2 1/2 years.
Now for my experience. I was sentenced to prison for 3 years at 50%, meaning I would have to do 1 year 9 months, less with good time. At IDOC receiving intake, I had an extensive medical, dental and mental evaluation to determine what my needs were. The IDOC was informed of my bladder issue and the need to use a 14 French catheter every time I needed to urinate. This was noted in my medical chart which followed me to my parent place of incarceration. When I was transferred, the Nurses their did an assessment of my condition and updated the medical chart, stating they were aware of my medical condition and needs. Within 24 days of being at my parent place, the HCU ran out of the 14 French catheters I used due to an enlarged prostate. The 16 French was difficult to get inserted without causing pain and on the few times of attempting the 16 French, they wouldn’t enter before I gave up because of pain and discomfort. Anyway, the HCU ran out because they weren’t ordered. I was told by the nurse to wash, with soap and water, and reuse the old ones. I was also told to save the used ones and bring them back to the treatment line in order for me to get new ones or they (the Nurses) won’t provide me with the new treatment catheters.
I was allowed to have 8 catheters in my possession at any given time, weather used or unused. Most days I would only use 4 catheters, and having 8 on hand meant I didn’t have to go to treatment line every day, I would go every other day unless I needed to. So, on this particular day I went to treatment line, no catheters to provide me, told to reuse or use the 16 French. I suggested they have someone go to Walmart or Walgreens to pick some up. The nurse told me this was not an option and to do what I was told to do or use the 16 French.
Still having a few left over, I was able to wait until the next night at treatment line where I attended and was told the same thing by another nurse, with the nurse from the night before standing in observation. I was told to do what the nurses had instructed me to do, or I would be written up for not following a direct order.
Let me set the scene for you a little bit. there are around 80 other guys using the same 5 sinks, washing hands, brushing teeth and so on.
There is no way I was going to take one of my used catheters out of the lubricated, urine-soaked plastic sleeve and stick it in the sink to wash without get the crap beat out of me or some other confrontation, not to mention you don’t know what’s on these dirty, nasty sinks and I could, at best, get a UTI. It’s bad enough I’m told to put the used ones in a plastic bag and place it under my bed mattress above where me and another inmate store our property boxes.
After being told this on 2 separate days, and on the 3rd day, after not having a proper way to urinate and going around 25 hours without urinating I was having severe pain and went to sick call that morning. I tell the nurse to either take me to the hospital or go get me the proper treatments I needed. The nurse goes into the back room and tells the DON where she comes out telling me to have a seat, she was going to get me catheters. about 45 minutes later she returns and provides me one to use right away to relive the pain and discomfort.
This happened 4 other times in my 1 year 5 months stay, (I had 4 months knocked off for good time) where I was in severe pain.
Remember I said I was told to save the used ones and return them, or I wouldn’t get the new treatments?
I was having issues with some of the guys because of the smell and urine dripping onto one of my Bunky’s property box, to where I feared for my safety, so I started throwing them in the trash. I explained this to the nurses, warden and HCUA and asked to have a locked box installed in the restroom to deposit the used ones in. I was told this was a security and sanitation issue and they weren’t going to do it, that I must continue to store them under my bed and make the returns. After throwing them in the trash and going to treatment line, I was refused the treatments because I didn’t have used catheters to return. The next morning, I went to NSC and received the much-needed catheters without being ask for used catheters. This happened around 10 times while I was there. I was written up twice for not following the rule to make returns of the used, and when I asked for a copy of the rule, or its location, where I could read it and understand the true intent. I was refused a copy of the rule and told to “save yourself further problems and do what your told”, no matter if it caused me problems with others in my room. Mind you, my Bunky, above me, is there for murder and I didn’t want confrontations with him or anyone else for that matter.
Bottom line here is… The nurses were enforcing an unwritten rule and punishing me by denying treatment for a serious medical need and as a result caused me severe pain and suffering for as much as 52 hours and as little as 8 hours. They wouldn’t make advancements to secure the treatment catheters from another source when they had a duty to do so and left me in pain, and instructed me to do a procedure that could cause me a UTI.
Were these nurses stepping outside their scope of practice by enforcing an unpublished rule and punishing me by not providing catheters to urinate which caused me pain and also by instructing me to reuse catheters? What else could I have done?
Thank you for any information and your honest opinion.
Douglas Manley from Illinois