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Understanding the Scope

B C C N M L E A R N I N G M O D U L E — W O R K B O O K

Of Registered Nurses Practice

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Introduction

This workbook offers activities that allow you to apply ideas presented in the on-line Learning Module. It is organized in two sections.

• Part 1 includes Workbook Activities that are related to various topic areas. As you work throughthemodule,youwillbedirectedtocompleteaspecificWorkbookActivity.Thissectionalsoincludespagesforyoutorecordyourreflectivethoughtsandinsightsrelatedtoyourexplorationin this module.

Some of these activities include case scenarios with associated questions. These provide an opportunityforyoutoapplytheinformationthathasbeenofferedinthemoduleinthecontextofthispractice-basedscenario.Whenyouhavecompletedtheseactivities,youmaywishtocompare your responses with those provided in the “Workbook Activities: Case Perspectives” located in Part 3.

• Part 2: This section of the workbook provides an opportunity for you to create a plan for your continued professional growth with the Registered Nurses Scope of Practice Standards. Asample Professional Development Plan is provided to help you in this process.

• Part 3 presents sample responsestoWorkbookactivitieswithcasescenarios.Theseresponsesprovide the perspectives of the course writer and others on the case scenario.

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part 1

Workbook Activities

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WorkbookActivity#1

Now that we have reviewed how nursing practice is described in the regulation please take a moment to think aboutyourownpracticeandtheactivitiesyouconducteachday.Whichactivitiesconstitutemostofyourpractice?Whicharerestricted?Whichonesarenot?Dosomerequireanorder?Itmaybehelpfultothinkofa typical work day, evening or night and write out your daily activities, then you may want to highlight those thatarerestrictedandcirclethosethatrequireanorder?YoumayfindithelpfultoreviewSection6and7oftheRegulation(linkbelow)andpotentiallysection8and9ifyouareeitheracertifiedregisterednurseoranurse practitioner.

Nurses (Registered) and Nurse Practitioner’s Regulation (BC Laws) http://www.bclaws.ca/EPLibraries/bclaws_new/document/ID/freeside/284_2008

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WorkbookActivity#22Charlies’s Story

Ather1600checkinCharliecantellthatMr.Holt’s,aclientwithtype1diabetes,conditionhaschanged.Assheaskshimhowhefeels,Charlienotes he is more lethargic, appears sleepy and seems to have trouble focusingonCharlie`squestions.ShenoticesthatMr.Holtseemstobefallingasleepassheistalkingtohim.WhenCharlieattemptstowakehim up with a gentle touch , he opens his eyes but seems to have trouble keeping them open. “I feel so tired, I can barely keep my eyes open”. CharlieknowsMr.Holtwasadmittedovernightwithgeneralweaknessafter a fall at home. She remembers, when reviewing his history, that he is diabetic and self-administers insulin at home.

Charliebeginsherassessmentbyadministeringabloodglucosetestwhichshowsabloodglucoselevelof3.2.Charliealsotakeshisvitalsigns.Hispulseis110/minandregular,BP140/60,and02Satsare99%onroomair.

Basedonherassessment,CharliedrawsaconclusionaboutMr.Holtsstatus.Shediagnoseshisconditionashypoglycemiarelatedtodecreasedbloodsugarlevel.Charlieknowsshecanimprovehisconditiontemporarily by giving him some orange juice that is kept by his bedside and by then following the decision support tool (DST) for hypoglycemia provided by her employer.

Indecidingtotreat,Charlieconsiderstherisks,benefitsandpossibleoutcomes.Inherjudgment,theoutcomeisreasonablypredictableandthebenefitsoutweighrisks.Shehastheknowledge,skillandjudgment to follow her organizational decision support tool and protocol for treating hypoglycemia, including managing any intended and unintended outcomes.

ExplaininghernextstepstoMr.Holt,shehelpshimdrinkhisglassoforangejuice.Reassuringhim,shewatchesforandchangesinhiscondition.Withinafewminutes,Mr.Holthasvisiblyimproved.Heappearsmore awake and states that he is feeling hungry.

CharliepagesMr.Holt‘sphysicianusingtheintercomsystemintheclient’sroom.Whenthephysicianarrives,Charlieconsultswiththetreatingphysicianandreceivesorders.Sheupdatesthecareteamanddocuments her ongoing assessment, diagnosis, treatment, and communication with the physician.

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ReflectingonCharlie’sStory

Considerthefollowingquestionsandjotdownyourthoughtsinthespaceprovided.Youmaywishtocompareyour answers with the discussion in Part #3, Case PerspectiveslocatedattheendofthisWorkbook.

1. Whatisthedifferencebetweendiagnosingadiseaseanddiagnosingacondition?

2. Whichhealthprofessionalgroup(s)areauthorizedtodiagnoseadisease?

3. Whatconditionsmightyoudiagnoseandtreatinyourpractice?

4. WhendiagnosingandtreatingaconditionwhichScopeStandardswouldyoufollow?

5. Whoholdsthesoleaccountabilityandresponsibilitywhendiagnosingandtreatingacondition?

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WorkbookActivity#3

Tara’s Story

Tara,aresidentialcarenurse,iscaringforMr.Junga87yearoldmanwhohas been her client for the last few months. As Tara conducts her morning vital signs and talks to her clients, she notices that Mr. Jung appears uncomfortable. Upon assessing him, Tara gathers enough information to diagnose bladder retention.

Mr.Jungexplainsthathehasnotvoidedinthelast12hours,hislowerabdomenisdistendedandhestatesthatheisinpain.Toconfirmherassessment and diagnosis of urinary retention, Tara conducts a bladder scan.Mr.Jung’sbladderisveryfull,thescanrevealsaurineretentiongreater that 500 mls.

AsTarahasdealtwithurinaryretentionmanytimesbefore,sheknowsexactlywhattodotohelpMr.Jungfeelbetter. After assessing the client, coming to a nursing diagnosis of a condition of urinary retention Tara has determinedtheneedforaninandoutcatheterization.Tara’splaceofworkhasaDecisionSupportToolforurinary retention which Tara reviews prior to carrying out the activity. She charts the outcome and assesses Mr. Jung once again post catheterization.

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ReflectingonTara’sStory

Usingthe“ActingwithinAutonomousScope”ReflectiveTool,(linkbelow)considerthefollowingquestionsand jot down your thoughts in the space provided. You may wish to compare your answers with the discussion in Part #3, Case Perspectives locatedattheendofthisWorkbook.

1. InTara’scase,whoisresponsibleandaccountablefortheactivityTarachosetocarryout?

2. Whatotheraction(s)shouldTaratakeinthiscase?

3. Tara’sorganizationhasaDecisionSupportToolinplaceforurinaryretention.WhatwouldTaraneedtodoifthis was not the case?

4. WhatimportantcomponentoftheActingwithinAutonomousScopestandardsisnotincludedinthedescription of this case?

5. If you were Tara, what would be your clinical decision making process? Describe, in detail, what you would do.

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Acting Within Autonomous Scope of Practice Reflective Toolhttps://www.bccnm.ca/Documents/learning/modules/ASOPthinkingtool.pdf

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WorkbookActivity#4

Sergei’s Story

Sergei,aregisterednurse,worksonamedical/surgicalunit.HisclientMrs.Whiteis67yearsoldandhasrecentlyundergonehipreplacementsurgery.ItisnowtimeforMrs.WhitetostartwalkingsoSergeicontactsthe Physio Therapist for an assessment and mobility plan.

The Physio Therapist conducts the assessment and provides a client-specificorderthatfocusesonMrs.White’scurrentabilitytomoveandstrengtheningandtherapeuticexercisestorestoreherwalkingability.

Usingthe“ActingwithClient-SpecificOrders”ReflectiveTool,(linkbelow)considerthefollowingquestionsand jot down your thoughts in the space provided. You may wish to compare your answers with the discussion in Part #3, Case PerspectiveslocatedattheendofthisWorkbook.

1. Beforeactingonthisclientspecificorder,whatmustSergeiensure?

2. Whatshouldtheclientspecificorderinclude(theactualwrittendocument)?

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Acting With Client Specific Orders Thinking Toolhttps://www.bccnm.ca/Documents/learning/modules/ACSOthinkingtool.pdf

BCCNM Acting with Client-specific Orders Web Page:https://www.bccnm.ca/RN/ScopePractice/part2/acting_orders/Pages/Default.aspx

understanding the scope of registered nurses practice workbook

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WorkbookActivity#5

Steve and Julie’s Story

Steve,anexperienceRN,worksonamedical/surgicalunit.HeiscaringforMrs.Chana60yroldwomenwithType1diabeteswhocameinwithalargediabeticfootulcer.SteverealizesthatMrs.Chanwouldbenefitfromsomewounddebridementandspecificwoundcare.Knowingthatdeterminingthespecificsfortheseactivitiesisbeyondhisowncompetence level, Steve calls on Julie a wound clinician to assess his client.

Julie, a wound care clinician, who is also an RN, conducts an assessmentandwounddebridementwithMrs.Chanandthenwritesupaclient-specificorderoutliningthewoundcarenecessarytocareforherfootulcer.ThisclientspecificorderistobecarriedoutdailybytheRN on shift.

Usingthe“GivingClient-SpecificOrders”ReflectiveTool,(linkbelow)considerthefollowingquestionsandjot down your thoughts in the space provided. You may wish to compare your answers with the discussion in Part #3, Case PerspectiveslocatedattheendofthisWorkbook.

1. Wheremustthisorderbewritten,whatimportantrequirementsmustthisordermeet?

2. Whoisaccountableandresponsibleforthisclientspecificorder?

3. Asidefromregulatoryrequirements(suchasBCCNM`sstandardslimitsandconditions),whatotherrequirements must Julie and the RN on shift acting on the order follow?

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Giving Client Specific Orders Thinking Toolhttps://www.bccnm.ca/Documents/learning/modules/GCSOthinkingtool.pdf

BCCNM Scope of Practice Standards Web Pagehttps://www.bccnm.ca/RN/ScopePractice/Pages/Default.aspx

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NotesfromReflectionPoints

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AffirmationsandInsights

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part 2

Growth Planning

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WorkbookActivity#66 My Plan for Professional Development/Growth

Goals

1.

2.

3.

Action PlanPeople or places that I can investigate for learning strategies to help me meet my goals for growth and ongoing development are:

1.

2.

3.

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My Plan for Professional Development/Growth

Strategy Resources I need to implement this strategy

Target completion date Other thoughts

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Reminder: Add your completed action plan to your Quality Assurance Portfolio/My Professional Plan.

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WorkbookActivity#66 Goals

1. To increase my understanding of what it means for me to be a self-regulating professional.

2.

3.

Action PlanPeople or places that I can investigate for learning strategies to help me meet my goals for growth and ongoing development are:

1. Review Learning Resources section of this module

2. Assess Organizational policies related to activities defined within Autonomous Scope of Practice

3.

My Plan for Professional Development/Growth: An Example

Review BCCNM resources related to Autonomous Scope of Practice

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My Plan for Professional Development/Growth: An Example

Strategy Resources I need to implement this strategy

Target completion date Other thoughts

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Reminder: Add your completed action plan to your Quality Assurance PD Plan/My Professional Plan.

1. Reviewdocumentsidentifiedin LearningResources sectionof module

2. Havediscussion withunit Educatorrelated toAutonomous Scopeof PracticeActivities andrelevant policies& guidelines

1. None – justdownload thedocuments fromthe Learningresourcessection!

2. Can do thiscasually and/or in scheduledmeeting time asneeded.

1. Within thenext week

2. Within thenext month

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part 3

Workbook Activities and Case Perspectives

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ReflectingonCharlie’sStory

1. What is the difference between diagnosing a disease and diagnosing a condition?

Conditionsalwayshaveassociatedsignsandsymptoms.Aconditionmayresultfromaknowndiseaseordisorderoritstreatment.Forexample,aregisterednursemaydiagnosehypoglycemiainaclientwithdiabetes,urinary retention in a post-operative client or angina in a client with a history of coronary artery disease.

Otherconditions,suchashypoxiaorpostpartumhemorrhage,mayresultfromamedicalproblemsuchasan undiagnosed disease or disorder. In these situations, a registered nurse may diagnose and stabilize the condition until a physician or nurse practitioner diagnoses the underlying disease or disorder.

2. Which health professional group(s) are authorized to diagnose a disease?

InB.C.,diagnosing(adisease,disorderorcondition)isarestrictedactivitygrantedtosomeregulatedhealthprofessionals. For instance, physicians and nurse practitioners are authorized to diagnose diseases, disorders andconditions;andcertifiedpracticeregisterednursesareauthorizedtodiagnoseaverylimitednumberofdiseasesanddisorders.Registerednurses(otherthancertifiedpracticenurses)havetheauthoritytodiagnoseconditions only.

Under the Nurses (Registered) and Nurse Practitioner Regulation, you can make a nursing diagnosis that identifiesaconditionasthecauseofaclient’ssignsorsymptoms.Anursingdiagnosisisaclinicaljudgmentaboutyourclient’sphysicalormentalcondition.Itinvolvesdrawingaconclusionaboutwhat’scausingthesignsorsymptomsyou’verecognized.

3. What conditions might you diagnose and treat in your practice?

SeelinkonBCCNMWebSite:https://www.bccnm.ca/RN/learning/scope/diagnosing/Pages/Default.aspx

4. When diagnosing and treating a condition which Scope Standards would you follow?

The Regulation also authorizes you to carry out certain restricted activities without an order to assess for or treataconditionyou’vediagnosed.Forexample,youmayinsertaurinarycatheter,suctionatracheostomy,irrigateanostomy,oradministeroxygenoradministerIVfluids.Thestandardsforactingwithinautonomousscopeofpracticesetoutexpectationsfornursescarryingoutactivitiesautonomously.

5. Who holds the sole accountability and responsibility when diagnosing and treating a condition?

Whenyoudiagnoseanddecidetotreatacondition,youaresolelyaccountableforthediagnosis,appropriatetreatment,andyourclient’soutcomes.Decidingtocarryoutanactivitywithinautonomousscopeofpracticerequires a greater level of knowledge, skill and judgment than carrying out the same activity with a client-specificorderfromanotherhealthprofessional.

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ReflectingonTara’sStory

1. In Tara’s case, who is responsible and accountable for the activity Tara chose to carry out?

Only Tara.

2. What other action(s) should Tara take in this case?

CommunicatewithotherhealthcareprofessionalsinvolvedinMr.Jung’scaretoensurecontinuityofcareandincrease best client outcome.

3. Tara’s organization has a Decision Support Tool in place for urinary retention. What would Tara need todo if this was not the case?

Communicateandcollaboratewithhealthcareteam,ensurethatherorganizationsupportsherprocessanddecisions/actions of acting within autonomous scope and knows her role, responsibility and applications of thestandards when acting within autonomous scope.

4. What important component of the Acting within Autonomous Scope standards is not included in thedescription of this case?

Obtaining consent from client.

5. If you were Tara, what would be your clinical decision making process? Describe, in detail,what you would do.

Assess, talk to client, diagnose condition, ensure you know your responsibility, your role, think of potentialoutcomes, use evidence, obtain consent….

Link on BCCNM Web Site:https://www.bccnm.ca/RN/ScopePractice/part2/autonomous/Pages/Default.aspx

Acting Within Autonomous Scope of Practice Reflective Toolhttps://www.bccnm.ca/Documents/learning/ASOP_thinking_tool.pdf

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ReflectingonSergei’sStory

1. Beforeactingonthisclientspecificorder,whatmustSergeiensure?

• Theorderedactivityiswithinhisscopeofpractice(asoutlinedintheRNRegulation)• ThatheisactinginaccordancewithanyBCCNMstandards,limitsandconditions.• Thatheisactinginaccordancewithhisorganizationalpoliciesandprocedures.• Sergeimustbesurehehasthecompetencetocarryoutthisactivitysafelyandethically.

2. Whatshouldtheclientspecificorderinclude(theactualwrittendocument)?

• Beclientspecific• Clearandcomplete• Documented,legible,datedandsignedwithauniqueidentifiersuchasawrittensignatureofan electronicallygeneratedidentifier.

• ContainenoughinformationforSergeitocarryoutthisactivitysafely

BCCNM Acting with Client-specific Orders Web Page:https://www.bccnm.ca/RN/ScopePractice/part2/acting_orders/Pages/Default.aspx

Acting With Client Specific Orders Thinking Toolhttps://www.bccnm.ca/Documents/learning/modules/ACSOthinkingtool.pdf

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ReflectingonSteveandJulie’sStories

1. Where must this order be written, what important requirements must this order meet?

• Client’spermanentrecordandmustbesignedorbeaccompaniedbyauniqueidentifier.• Becompleteandclear• Haveenoughinformationfortheshiftnursetocarryouttheactivitysafely• Documentedandlegible

2. Whoisaccountableandresponsibleforthisclientspecificorder?

• Julie,theRNwhogivestheorder

3. Aside from regulatory requirements (such as BCCNM`s standards limits and conditions), what other requirements must Julie and the RN on shift acting on the order follow?

• OrganizationalPoliciesandProcedures• SinceJulieisaNon-Listedhealthcareprovider,anyRNsonshiftmustensuretheyhaveindividual

competence to carry out this activity and follow Acting with Autonomous Scope Standards.

Giving Client Specific Orders Thinking Toolhttps://www.bccnm.ca/Documents/learning/modules/GCSOthinkingtool.pdf

BCCNM Scope of Practice Standards Web Page:https://www.bccnm.ca/RN/ScopePractice/Pages/Default.aspx

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