Nursing Clinics and Scope of Practice. What Do You Think?

20130123-1At the last Essentials of Correctional Medicine conference, Dr. Marc Stern gave a thought-provoking lecture about the proper use of nurses in the correctional setting. I have to admit that his talk was a bit controversial; some of the nurses in attendance were uncomfortable and even a little offended.  But whether you like Dr. Stern’s talk or not, his thoughts deserve some consideration.

The main thrust of his talk was to compare how nurses are used outside of corrections—the community standard as it were–as opposed to how nurses are used inside jails and prisons.  There are quite a few differences.  Why is this so?  And if nurses are used inside of correctional facilities differently than the community standard, is this proper?

Dr. Stern brought up two distinct differences between how nurses are used in the community and how they tend to be used in corrections:  Acute Care and Chronic Care.  I am going to discuss the Acute Care issue today and the Chronic Care issue in my next post.

The Nursing Role in Acute Care Clinics–Community vs. Corrections

The single major difference between how nurses are used in the community and how they are used inside correctional facilities is this: in the community, nurses do not run acute care clinics–ever.  Nurses in the community do not diagnose or prescribe treatment.  It does not matter whether you go to your doctor’s office or a hospital emergency department or a “Doc-in-the-Box” urgent care clinic or even one of those mini-clinics you find in grocery stores nowadays.  In each case, you will be seen by a medical practitioner of some sort; whether a doctor, a physician assistant or a nurse practitioner.  Nurses will be there, but in the role of assisting the practitioner.  It just will not happen in the community that a patient will be seen only by a nurse—no practitioner in sight—who does an examination, makes a diagnosis like, “You have bronchitis,” and hands out a prescription.

On the other hand, acute “sick call” clinics in correctional facilities are commonly run only by nurses.  These nursing clinics tend to be of three main types:

  1.  Triage clinics.   In this type of clinic, a nurse sees every patient who puts in a medical request and schedules them to see a practitioner depending on the urgency of the complaint.  For example, a patient complaining of abdominal pain might be scheduled for the very next medical clinic whereas a patient complaining of dandruff might be scheduled a week out.  The Triage nurse could also have the on-call practitioner come in urgently to evaluate a patient with, say, chest pain or decide to send that patient to the ER.  However, in this model, nurses never diagnose or prescribe treatment.
  2. OTC clinics.  “OTC” stands for “Over-the-Counter” medications that do not require a doctor’s prescription.  In this type of nurse clinic, a nurse again sees every patient with a medical request and schedules medical clinic appointments, but also is authorized to dispense over-the-counter medications for common minor complaints.  For example, a patient with abdominal pain still would be scheduled in to medical clinic, but a patient with athlete’s foot might be given OTC clotrimazole cream by the nurse without the patient ever seeing a practitioner.  Some facilities have quite detailed protocols to guide nurses in this endeavor, but not all.
  3. Full Service Nurse Clinics.  In some correctional facilities, nurses take care of almost all sick call patients.  The nurse will still schedule complicated patients to see the practitioner, but will take care of other, simpler, problems even if these require a prescription medication.  If a nurse thinks that a patient needs a medication requiring a doctor’s prescription, he/she usually will call the on-call practitioner for authorization.  An example would be a female inmate thought to have a Urinary Tract Infection.  The nurse would call the practitioner for orders, say an antibiotic, and then administer it.    Sometimes, this patient will be seen by the practitioner in a subsequent clinic, but not always.

As Dr. Stern pointed out in his talk, it is clear that this system of using nurses in jails and prisons is very different from the “community standard.”  Dr. Stern also pointed out that in many correctional facilities, the nurse performing these tasks is not an RN, but an LPN or even a “Correctional Medical Technician” with even less formal medical training than an LPN.  The concern is that by running acute care clinics, which involves making diagnoses and prescribing treatment, nurses may be exceeding their scope of practice.

Why Are the Two Systems Different?

Personally, I can easily see how this system of nursing duties evolved within corrections.  Community urgent care clinics have a practitioner in attendance at all times.  These clinics are never staffed with nurses only.  But jails and prisons are not that way.  Consider very small jails, for example, where the doctor’s sick call clinic may only be held once a week.  Someone, then, has to evaluate inmate medical requests to decide if the inmate can safely wait until the next scheduled clinic, which may be days away.  You certainly don’t want the inmate with appendicitis to wait a week to see the doctor!  And the jail nurse is certainly a better choice to do this evaluation than a detention deputy!

But what if the inmate complaint is so simple that it only requires an Over-the-Counter medication?  Say heartburn?  The inmate can certainly wait until clinic but why can’t the nurse just give out some OTC ranitidine?  Or foot fungus cream for athlete’s foot?  Is it even ethical to make the inmate suffer until clinic for such a simple problem?  On the outside, the inmate would not even have to go to medical.  They could just go to the store and buy ranitidine.  Can’t a nurse just give the patient some OTC ranitidine?

Other simple inmate complaints can be just as easily resolved with prescription medications.  Take the young healthy woman who has the classic symptoms of a urinary tract infection: dysuria, urgency and frequency.  Can’t we get the antibiotics started before the doctor’s clinic?  Do we make her wait?  And what about other, more serious, medical problems like alcohol withdrawal that absolutely should not wait until the next sick call.  Librium must be started now, whether there is a doctor on site or not.

But then, it is but a short, dangerous step to the next level:  By the time the doctor comes in for clinic, the woman with the UTI is cured!  The alcohol withdrawal patient is doing well!  The patient with heartburn has no complaint!  Isn’t it just a waste of the doctor’s valuable time to see these asymptomatic patients?

In the end, you have the scenario where a nurse has made a diagnosis and perhaps prescribed treatment without a practitioner ever having seen the patient and maybe even without ever having been contacted!  Somewhere along that continuum is a fine line that, when crossed, means that nurses are diagnosing and treating beyond their scope of practice.

In prisons, where a practitioner may be present in the facility every single day, it may be possible to run acute care clinics as they are done on the community.  However, it also may not be feasible.  Since I don’t practice in a prison setting, I will leave the discussion of the proper role of nursing clinics in prison to my prison based colleagues!  Please comment below!

However, in jails, it is simply not possible to run acute care clinics like the community standard.  No 50-bed jail can afford to have a doctor show up for clinic every day.  Even large jails don’t typically have practitioners on site every day.  There has to be some sort of partnership with nurses to triage medical requests and to take care of simple problems.  However, jails should take care not to cross the line where nurses exceed their scope of practice!

The following reflects my personal opinions on the subject:

  1. Nurses should have a protocol or guideline to follow when they evaluate simple complaints that can be treated with OTC medications.  Patients with complaints like “I have athlete’s foot and need cream for it” or “I have heartburn–can I have some Zantac?” do not necessarily need to be seen by a doctor since they do not need to see a doctor on the outside to obtain these items.  But even these simple complaints can be fraught with some danger—like when the guy with “heartburn” is really having a heart attack.  Nurses should have written guidelines that indicate when OTC remedies are appropriate and what “Red Flags” indicate a referral to clinic.  If nurses have such guidelines, they are not diagnosing and treating independently; they are instead assisting patient to obtain appropriate OTC medications.
  2. Why make inmates see a nurse to get OTC medications in the first place?  People outside of jail don’t have to go to a clinic to get Zantac or foot fungus cream or whatever.  They just go to the store and buy them!  So why do we make them do it in jails?  It is a waste of both the nurse’s time and the inmate’s time.  Put appropriate OTC medications on the commissary (see You Need a Medical Commissary in Your Facility! and Obstacles to a Medical Commissary Program.
  3. If a nurse thinks a patient needs an urgent prescription drug before the next medical clinic, the on-call practitioner must be called for an order! Nurses should not start prescription medications based on protocols alone.  That is not done in the community; it should not be done in correctional facilities.  For example, if a nurse sees a MRSA lesion and wants to start antibiotics before the next clinic, he must call for an order.  Does an alcoholic need to begin therapy for withdrawal tremors?  Call.  If these calls are not made, then the nurse has diagnosed and prescribed treatment independently, outside of the scope of practice.  The only exception to this rule is emergency treatment, like epinephrine for anaphylaxis.
  4. Every patient who receives a prescription medication should be seen by a practitioner!  I don’t mind authorizing antibiotics over the weekend for a woman with a UTI.  But I then am obligated to see her, however briefly, in my next medical clinic.  It doesn’t matter if she is better—that just means that the clinic visit will be brief.  But if I prescribed the medication, I need to document a history and an examination in her chart.  If I don’t, the nurse again diagnosed and prescribed beyond her scope of practice, albeit with my “rubber stamp.”  Interestingly, here in Idaho, the Board of Medicine recently condemned the practice of prescribing medication without examining the patient.  The Board was specifically addressing situations like when a family member or friend calls and says, “I have a sore throat.  Will you call something in?”  But the principle applies to this situation in corrections, as well.  If I prescribe something, I need to see the patient and document a history and physical.

As always, I have expressed my own opinion here.  Feel free to disagree.  I might be wrong!  But if you do disagree, please comment and explain why!

Next Post:  Chronic Care Clinics in Corrections vs. the Community!

In the Essentials of Correctional Medicine Conference, Dr. Stern’s lecture on nursing roles raised some eyebrows.  What is your opinion on nursing roles in corrections?

11 thoughts on “Nursing Clinics and Scope of Practice. What Do You Think?

  1. All respect to correction nurses – yet, everything you have noted is important to consider. A few thoughts…
    The ‘what if’ concern is not relegated to nursing – the reality is that we all need to know what we don’t know and have the humility / honesty to ‘get another set of eyes’ on something if we’re not comfortable with the issue.
    The best ‘natural’ correction nurse seem to come from the ER – they have the broad range of assessment skills and thought process that ‘works’ in the correction environment – they are also accustomed to extending their assessment (EKG, UA, Pregnancy test, etc.) as is appropriate to the patient and the efficiency of the ‘provider’.
    One last thought, my experience in the military has brought with it the understanding that patient care can be enhanced with appropriate use of expanded roles for para- / professional staff. A set of guidelines (protocols or better yet a type of credentialing*) is critical to this process – helps to address liability too.
    * a tasks list that – may accomplish on a routine basis; may accomplish only with consultation; must have direct supervision to accomplish.

  2. Excellent, excellent post. For starters, I am an RN. (All nurses henceforth will be she/her) The first thing I know about nurses. Not all nurses (RN/LVN) are created equally. Be it education, experience, level of awareness, overall critical thinking or general skills capacity. Any excellent nurse will tell you, the first thing they do is assess the capabilities of whomever they are working with; this is basic risk management, particularly when in the role of delegation and supervision. Often those who are not capable are the very ones who will not seek the resources to make the decisions that they must make, unfortunately. A great nurse knows her limits and works within her resources; she will not exceed her scope, regardless of her abilities and talents. A great nurse can still make a mistake. We are all human and capable of error. IMHO Medicine is a series of checks and balances, within the community and out of the community. I also believe jails and prisons are part of the community and need to be further drawn into it. This is why I believe in Standards, and review of clinical practice. It is why I would push for correctional health to become e community oriented, and to have to meet the same criteria that any outpatient long term or acute care clinic has to meet. Protocols are great when clearly defined, and the best protocols will always have followup with an advanced pratitioner in the event of prescibing. I type of credentialing is critical, I agree!

    • Thanks for the comments! Doctors, as well as nurses, need to know their limitations and when to call for help. I am an emergency physician by training and so feel pretty comfortable with assessing abdominal pain, chest pain, etc. But I am not well trained and need help in many other medical fields, such as cancer management, HIV treatments, complicated dermatology and rheumatology and on and on. So just like nurses need to know when to call others for help, so do doctors. As you implied, we are a team and the best medicine is practiced as a team–we rely on each other and we watch each other’s backs!

  3. I should preface my whole comment that I am an RN with 17+ years of all different kinds of nursing experience under my belt. I believe that probably allows me to be a bit more critical of the profession. Couldn’t agree with you more Dr. Keller! It is my belief, after hearing Dr Stoutin talk about the presentation and subsequent reactions from nurses in attendance, that it is likely the ones practicing outside their scope squawking the loudest. Nurses need to read up on exactly what their scope of practice is and then function within those boundaries. LPNs who are angry because they aren’t allowed to do as much as an RN need to cork it and go back to school to obtain the degree and licensure. Likewise, RNs who get hot under the collar when told they can’t do certain things need to shut up and go back for their NP degree. There are RNs and LPNs who are incredibly intelligent and could very easily accept and excel with expanded duties but their licenses don’t cover them so it’s a moot point. Nurses need to stop all the whine-bagging and do what their degree and licensing body tell them they can do.

    Now, having likely angered some nurses out there, I definitely agree that correctional nursing is an altogether different beast than more “traditional” nursing roles! It takes a strong, confident and EXPERIENCED nurse to be successful in this role. I work in a smaller jail with anywhere from 100-170 inmates at a given time so my challenges are nowhere near what some of the larger facilities face. I have an incredible relationship with my MD and my PA which makes the job all the more fun. We function very much as a team as they rely on my ability to assess medical needs of patients and then effectively communicate the information to them. I rely on them to make the decisions. Do I call them 100 times during the week for every little thing? Definitely not. Do we have a million protocols in place for every potential healthcare need? Again, no. We do have protocols (thank you Dr Keller) and I have developed a certain level of trust with my providers. They can rest easy knowing I will not practice outside my scope, I will use common sense and critical thinking and that I know my role and have no interest in becoming a liability to them by doing things I ought not.

    • Hi Alex! That is a hard one. The only way I know of to obtain these protocols is either to write them yourself or else to “borrow” them from another facility that has written them.

  4. Nurses are put at a decided disadvantage in small county jails. But if you have been in practice many years, especially if you have practiced in small towns, small hospitals, rural areas, you know that in the past Nurses have generally done whatever they had to do if it wasn’t specifically proscribed. Thank God for dedicated Nurses. How many have delivered babies waiting for the Dr to arrive? Just as in marriage, most well-known successful doctors are standing on the shoulders of several hard working, dedicated, experienced Nurses. Even in big ERs. In a small rural county jail, of which there are many, a Doctor may see inmates an hour a week. Sometimes an hour every other week. “The Nurse” for that jail, may only be paid to be there a couple of hours a day or less. Most spend more time than that doing what they know needs done. The rest of the time, any medical triage or delivery is done by jailers who, hopefully, have a nurse or doctor they can call for the remaining 22 hrs a day. Scope of practice?

  5. I am a nurse with over 30 years of practice. I am a recent hire to a correctional facility. I am truly concerned about my liability related to working with LPNs who are clearly practicing beyond their scope of practice. On my first day of clinical orientation the nurse told me that they had a crash cart with all of the ACLS meds & equipment readily available. She spoke about initiating ACLS while waiting for EMS to arrive. I assumed this person was an RN… the end of the day…. I discovered that this person was an LPN. Clearly… ACLS meds IV push was a practice way beyond the LPNs scope of practice. I also observed her performing initial assessments on New clients. Looking at the work schedule, I discovered MANY days / shifts that only had LPNs working. (the HSA is an RN and was present in the facility but definitely not involved with the care of the clients or the activities performed by the LPNs. I attempted to look at the State Board of Nursing Scope of practice for LPNs only to discover a VAGUE decision tree to help determine if an activity was within the Scope of practice for an LPN, along with a generalized statement that the curriculum taught in the LPN programs determined the scope of practice, followed by the names of the schools. Then I went to the websites of the schools to see if I could find information about the curriculum. I was unable to find specific information that allowed for determination of the Scope of Practice.

    What liability does an RN have when working with an LPN who practices beyond the scope of practice?

  6. I have worked with Nurses for 30 years in correction medicine and I couldn’t agree with Dr Stern and his article was excellent. I have been caught in more than one law suit because the nurse didn’t have enough experience. although they called me for orders they missed the problem and never set him up for sick call. I could not do my job without the nursing team but in a correctional setting you have to careful and be on guard to prevent Lawsuit to institutional setting or the team that is involved with care of the patient. Again great article by Dr Stern.

  7. This was a great read, and brings up some very good points!

    Our jail is unique in our area (and from what I’ve heard, in many places) in that we employ paramedics in addition to nursing staff. I am one of those paramedics, and I’ve found that my ability to operate within the parameters of standing orders, according to my assessment of the patient, vital signs, symptoms, and other data (12-leads, I-Stat, etc.) has helped address some of the concerns mentioned in the article. We both work with an RN (mine has 20+ years of ER experience, so we make a great team), and our scopes of practice are such that there is good coverage for the majority of situations that arise within the correctional setting.

    • Thanks, Matt! I have also found paramedics to be a valuable resource in staffing jail medical units.

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