Vol. 17 •Issue 18 • Page 32
All Caregivers Limited In Their Scope of Practice
At the turn of the 20th century, the European and the American class structures were not as flexible as they are today. For example, if a father were a shoemaker, the chances were good that his son would be a shoemaker as well. Scope of opportunity was simple, to the point and long-term more than 100 years ago.
Citizens are caught up in the evolution of flexible career opportunities and freedom of choice when it comes to pursuing an occupation. The sky is virtually the limit when it comes to careers today, although there are some jobs for which you can’t readily apply. For example, it would be difficult to assume the role of The Donald. And it is important to remember that jobs like Chief Justice of the Supreme Court are reserved for a chosen few. Nor are Army recruiters likely to sign up someone for the rank of general. Buck private is a far better option.
Free will in selecting a career has become the standard for most businesses today, whether that business centers on health care, the law, sales, education or auto manufacturing. Those who select a particular career can soar to the top, based on their abilities, their setting, their co-workers and a certain amount of luck.
Once they have selected their career, however, individuals must also realize there are still ceilings and walls to define the boundaries for their future expectations. Nowhere are boundaries in place more than in health care, and caregivers at all levels must resist the temptation to exceed the limits of their abilities or what they are empowered to do.
Prinum Non Nocere (First Do No Harm) is the oath by which we, as heath care practitioners, are expected to live. In addition, we are bound by state, federal and professional guidelines, which are well-defined, regarding our scope of practice. The combination of regulations and professional oath establish limitations as to what we can and cannot do regarding patient care. Gray areas, however, do exist, and circumstances may present themselves, requiring an individual to cross a line in order to provide emergency care to a patient.
Decisions as to where the rubber meets the road and where your sense of duty and ethics lie often come into play.
Discord and Discussion
Scope of practice is often a target of discussion and sometimes discord between physicians and allied health personnel, especially as those in the latter groups sometimes attempt to expand statutory limits beyond their levels of educational and clinical training.
Safeguards, such as protocol arrangements placing physicians in a position of responsibility for overseeing the care of their patients, are routine.
The marriage between a scope of practice and the flexibility built into some training and education programs largely determine the care a patient receives and the level of care that is available. The relative position of the individual within the health care system governs the liability of the practitioner and the health care organization. Each member of the health care team has an important role to assume, but that role is limited in relationship to the overall care being provided.
Within such a framework, a respiratory therapist does not have the same duties as a radiologic technologist, a nurse, a physician or a health information specialist.
But in today’s health care environment, such limitations do not necessarily curtail individuals from a quest to expand their scope of practice and their sphere of influence. Some view barriers like prescribing medications, conducting some medical procedures and monitoring chronic diseases as nuisance regulations.
Clinging to Old Rules
Many caregivers today view some restrictions as unreasonable in view of staff shortages or funding shortfalls. But the various entities within the health care community do not view the situations through the same pair of glasses. What might appear to be a reasonable solution to a problem to a nurse or a therapist may be completely contrary to the thinking of a doctor or hospital administrator. Physicians, aligned under the umbrella of the American Medical Association (AMA), continually oppose what they believe to be inappropriate expansions of scopes of practice. Nurses, a huge group likewise operating under a protective blanket, also seek to expand their duties or protect their turf from outsiders.
Through all the political and educational twists and turns, the various health care professions themselves are continually evolving, shaping and re-shaping the manner in which they treat their patients. RTs too evolve as they incorporate increased knowledge and competencies within the framework of their care. For the majority of caregivers, the limitations to their scope of practice and the evolution to include new options are not problematic. They follow the ethical guidelines set forth for their group.
But the term “majority” or the word “most” are always problematic in terms of logic. Those words signify there are exceptions to the generalization being made. And unfortunately, there are individuals who break the law through criminal impersonation of a caregiver, fraud and illegal use or distribution of controlled substances.
In other instances, the behavior of a professional can exceed the boundaries of professional liability set forth in established guidelines.
At the same time, the behavior of a professional can be highly variable, depending on powers handed down by supervisors. Physician assistants (PAs) are an example. PAs are educated in a scholastic medical model and receive a broad-based, generalist education in primary care. The boundaries of their practice are typically fluid, evolving around the delegated powers made by the supervising physician. This arrangement allows for a flexible and often customized team relationship based on confidence and trust.
Because of this special type of relationship, PAs can specialize in the care of patients ranging from neonates to geriatric patients. Their scope of practice allows them to work in NICUs and adult ICUs, emergency rooms and long-term care facilities. PAs have a broad spectrum of work duties under various conditions and are considered the right hand of the physician-directed team.
Moral fiber and good character are personal traits one can only hope a candidate brings to the team table as a PA. However, granting privileges to a PA is not automatic. Those on the hiring end need to consult the National Practitioner Data Bank for malpractice claims and the Federation of State Medical Boards for records of disciplinary actions.
The same might be said for other caregivers. One hopes for the best on the hiring side.
Nurse midwives constitute another special category of caregiver. These individuals have a history going back to the early frontier days for providing primary health services to rural areas of the country. Having worked as a respiratory perinatal specialist in a level three nursery with a very active labor and delivery service, I have appreciated the risk level of crash deliveries and the scope of responsibilities a nurse midwife assumes even in a the controlled environment of a medical facility.
But their range of practice extends beyond the clinic doors. They can just as easily work in a patient’s home. A nurse midwife who does so during a delivery is operating at the extreme limit of the scope of practice.
Temptation is never far away for those who provide health care, of course. Consider the following two quotations:
“Temptation is an irresistible force at work on a movable body,” noted Henry Louis Mencken.
“Lead us not to temptation. Just tell us where it is at and we will find it,” wrote Sam Levenson
And then consider the following example of temptation allegedly played out in a respiratory care department. At night in one hospital, Efren Saldivar, portrayed by some writers as the Angel of Death, preyed on the helpless, allegedly administering fatal drug doses to those he considered hopeless in terms of recovery. As an increasing number of his patients died, talk of his magic needle spread among his peers, noted Paul Lieberman, a newspaper staff writer.
This was indeed an extreme example of practicing out of bounds of a scope of practice. Saldivar, whatever his intent or motivation, totally disregarded the rules, regulations, guidelines and ethics of the respiratory care profession.
In the process, the Angel of Death gave his fellow respiratory therapists a bad rap. It became easy for the general public to look askance at RTs, questioning whether there were others in the field giving fatal injections to their patients.
Saldivar is hardly alone in breaching a code of ethics. There are other examples of caregivers who cross professional lines to the detriment of their patients’ well being. Nurses, personal care attendants and doctors cross such lines from time to time. Rather than condone such behavior, caregivers have a responsibility to report it. They have a duty to contribute to their professional organization, which is, in turn, charged with building the public perception of the profession and protecting and perhaps even expanding the scope of practice of professionals within the group.
Just Say No
As the world spins frantically in the daily life-and-death struggles taking place in health care today, it is easy for stress, understaffing and heavy loads to cloud over the boundaries of accountability. It is sometimes easy for caregivers to be asked to do something not within their scope of practice. These requests must be met with an emphatic “No.”
When others want to fight that type of a response, RTs do have recourse. A simple question: “What about the word ‘no’ don’t you understand?” has served me well in the past when I have been asked to do something I believed to be unsafe or unethical.
Self-control is the barometer of your worth as a caregiver, especially when a life is in your hands.
Michael Donnellan is a California practitioner.