Scope of practice is a critical concept for professional practice. Within the healthcare professions, we are defined by our licenses. State boards of nursing define specific scopes of practice within their jurisdictions. Countless articles, presentations, and conversations have debated the boundaries and overlap of aides, licensed practical nurses (LPN), registered nurses (RN), and advanced practice nurses (APRNs). These discussions help us to define and develop practice. Without robust discussion, nursing practice would grow stagnate and misaligned with the needs of the community. Today, there is a new layer to questions of scope of practice that must be tackled. Patient and family caregivers are performing more and more technically complex tasks independently. A growing number of these tasks are defined under scope of practice laws. This sets up a conflict that has been captured in recent headlines.
In today's connected news world, the story of a local home healthcare aide in Washington state made its way to national circulation. An aide was suspended by her employer and is under investigation by the Department of Health for actions potentially violating her scope of practice.
“The investigation stems from changing a quadriplegic client's clogged catheter line. The client showed signs of a severe infection, including sweating, nausea, an extended stomach and bright red skin, she said. Jacobson (the aide) is not allowed to drive clients, and when she suggested calling 911 the Longview-area client told her he couldn't afford an ambulance.” (Fairbanks, 2019).
The story reports that, after the patient refused to go to the hospital, the aide was left choosing between following the patient's choice and his directions to change the catheter or watching her patient suffer, knowing that no action posed a risk to the patient's life.
There are several unknowns in this story. I have not found reporting on the care plan for managing this catheter. It is implied, but not stated, that the patient had the knowledge but not the functionality to change the catheter. The outcome of the catheter change is unclear as well. I don't know the details of the aide's role, and nothing about the employer. The reporting suggests that the only two options open to the aide were to call an ambulance against patient wishes or perform a sterile catheter change under the direction of the patient. No mention is made about calling the employer, primary care provider, or an RN for guidance. Despite these and many other unanswered questions, the issue of scope of practice is center stage.
In home healthcare, patient and family education is the cornerstone of almost every care plan. Empowering independence and maximizing functionality is a central goal of all care delivered at home. As a result, patients and family caregivers learn a variety of skills such as how to feed a dependent person, turning and repositioning in bed, and use of assistive devices to name a few. These skills are core to the generally accepted skills of an aide. A growing number of family caregivers are learning advanced skills like tube feeding, urinary catheter management, or medication administration via central lines. In institutional settings, these skills are limited to those with a specific license. In most states, only RNs can administer medications with a central line. Thus, there is a growing challenge. As a profession, it is time to discuss the complexities of teaching the layperson-family caregiver to perform skills otherwise limited by scope of practice laws.
There are differences. Laypersons learning these skills are typically learning the skill in isolation. Licensed professionals are expected to posses a broader scope of knowledge supporting and informing the performance of the technical skill. But are we prepared to explain this to our patients and families?
When a family welcomes a paid caregiver into their home, is it unreasonable that they would expect the aide or LPN to perform the same skills they do? Debates about what kind of skin cream aides can apply when providing incontinence care are still active. What qualifies as a medicated cream and what needs to be on the plan of care is a common discussion in home healthcare and hospice meetings. In a world where family caregivers are not just empowered but expected to perform sterile techniques, how do they understand the refusal of the aide to help? Do we have an answer?
This challenge isn't limited to aides. With the ongoing development of hospital at home programs, primary care at home and alternative payment models, the pressure to bring a greater variety and complexity of procedures into homes will continue to increase, placing more and more emphasis on the layperson to perform these skills. This direction may be supportive of patient preference and is presumed to be cost effective, but are we prepared to manage and respond when a conflict like the one in this story occurs?
How are we supporting our team members to respond to these situations? In the articles about the case in Washington, the aide is to be applauded for her commitment to the patient. But how was she prepared to respond to a developing emergency? How did her education, experience, and workplace support her to manage the issues? How did the system prepare her to arrive at the right decision? Is there a clear “right” decision?
From all the reports, the patient in this case had a successful clinical outcome and his decision-making power was fully embraced. Both excellent outcomes. But as the aide is currently unable to work, the ends did not justify the means. I am troubled to think that the only options the aide perceived were to honor patient choice or protect herself. In this case, the patient's choice may even have been against his own self-interest and perhaps motivated by limited knowledge of alternatives. This case is concerning from many perspectives, including the challenge of scope of practice definitions with empowered patients.
Self-regulation is a defining attribute of all professions. Scope of practice laws are the tangible method we use to define the practice of nursing and identify ourselves. This is not the first time the lines between providers have blurred. As APRNs have evolved into independent licensed providers, time and effort was and is invested to delineate the similarities and differences between an ARNP and a physician. But these differences are difficult for the average patient to identify. From their view, it is difficult to define or even recognize there are two different groups, never mind understand the differences. The same is true for patients and families at home. When they are taught to perform health-related skills, it is reasonable for them to assume that every member of the care team can perform the skill.
At its most challenging, I wonder why is it acceptable for a layperson to perform skills that an aide is barred from doing? If the risk of harm from the skill or procedure is greater than the level of practice of aides, how is it less risky for the general public? How are we preparing to manage and respond to these blurred lines?