How Can I Solve a 'Scope-of-Practice' Dilemma?

Carolyn Buppert, MSN, JD


October 01, 2013

Decision-Making About Scope of Practice

After looking at the Tennessee Board of Nursing Web site, I have a little more data on how the Board of Nursing in Tennessee views nurse decision-making when nurses are faced with a scope-of-practice dilemma. In their "Decision-Making Guidelines," the Board directs nurses through steps of decision-making. The first step is to describe the activity to be performed.

The second step is to answer the question: Is the activity specifically permitted or prohibited in any existing statutes, regulations, or rules? Here, the activity is prohibited by Board policy. We could stop right there, but let's go on.

The third step is to answer the question: Does the educational preparation of the nurse provide the knowledge base and skills necessary to perform the activity? I am not certain, but I doubt that most LPNs are prepared to change a tracheostomy in an emergency situation. Does your organization provide such training for its LPNs?

The fourth step is to determine whether the activity is consistent with national standards of practice or supported by data from the nursing literature. I found no national standards of practice and no data on this in the nursing literature.

However, I found that the Mississippi Board of Nursing does allow LPNs who are appropriately trained to change tracheostomies if:

The nurse is educated and competent in the procedure and this education and competence are documented initially and on an ongoing basis;

The trach is well-healed (for replacement);

There is a medical order for the procedure;

The nurse practices according to generally accepted standards;

All the necessary resources are available;

The patient's status does not contraindicate the procedure; and

The agency/facility has policies and procedures addressing all aspects of this issue. (Policies should specifically address protocols related to elective vs accidental dislodgment of tracheostomy.)[1]

However, like Tennessee, the New York Board of Nursing prohibits LPNs from changing the outer cannula.[2]

So, there is a difference in standards from state to state, and there doesn't appear to be any national standard. The safe thing for an LPN and a facility to do is follow strictly the dictates of the state's Board of Nursing.

Your situation provides another example of how nurses often face risky, heart- and mind-twisting legal and ethical dilemmas. An LPN might believe that he or she is competent to replace a tracheostomy in an emergency and may believe that this would save the patient's life but is prohibited from this activity. If the LPN choses to violate Board policy, attempts to replace the tracheostomy and fails, and the patient dies, then the LPN may be sued for malpractice and disciplined by the Board. If the LPN succeeds, he or she will be a hero, but he or she nevertheless will have violated a policy of the Board and will surely face a disciplinary process. The best choice is to follow the Board's rules. If LPNs are truly educated and trained to change tracheostomy cannulas in emergencies, then facilities should pursue discussions with the Board about this matter.


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