Nursing Scope Of Practice R2598 Pdf Download
Germaine Greenweig
In this, the first of two articles, legal limitations in the practice of the primary health care nurse in the Republic of South Africa, having direct implications for the achievement of the goal 'health for all by the year 2000', are discussed. The questions which had to be answered by means of research relate to the nature and scope of the limitations as well as to how these limitations should be addressed in order to facilitate the practice of the primary health care nurse. A content analysis was done and recommendations formulated to amend and/or clarify certain health legislation. It is recommended that an empirical investigation be done to verify the results.
PIP: Nursing manpower constitutes 67.8% of total health manpower in South Africa. Given the maldistribution of nursing manpower with respect to urban/rural distribution, primary care nurses have a particularly important role in providing care to those in need in the country. The author discusses legal limitations in primary health care (PHC) nursing practice in South Africa with focus upon the nature and scope of the limitations as well as how the limitations should be addressed to facilitate the practice of the PHC nurse. A content analysis was undertaken, while recommendations were formulated to amend and/or clarify certain health legislation. The following limiting legislative provisions were found: the Medical, Dental, and Supplementary Health Services Provision Act section 36(1)(b) and (c) with respect to the physical examination and diagnosing of a patient and the prescribing of treatment; the Pharmacy Act section 29(2)(d) and (e) on advice about medication and limiting the supply of medicine to inpatients; the Nursing Act section 38A with respect to limitations upon nurses in certain PHC areas and Government Notice R2598 with respect to the scope of practice of the registered nurse and the definitions of diagnosis, prescribing, and treatment; and the Medicines and Related Substances Control Act section 22A(12) limiting the functions of PHC nurses. In closing, the author recommends an empirical investigation to verify study results.
Objective. To identify and describe current clinical nursing practice in fluid balance monitoring and measurement accuracy in ICUs, conducted as part of a broader study in partial fulfilment of a Master of Nursing degree.
The American Association of Critical-Care Nurses' (AACN) Scope of Practice Statement states that 'critical care nursing is a dynamic process, the scope of which is defined in terms of critically ill patients, the critical care nurse and the environment in which critical care nursing is derived' (American Association of Critical-Care Nurses 2007:1). Nurses in the ICUs are exposed regularly to huge demands in terms of fulfilling the many roles that are placed upon them. Unit managers, in particular, are responsible for the efficient management of the units. In the ICU, the unit manager is involved at a level different from critical care nurses. The critical care nurses are mainly involved in the nursing care of their patients only, whilst the unit manager is involved in the overall planning, organising, leading and controlling of the activities in the unit. Nursing management, according to Swansburg and Swansburg (2002:27), refers to performing the functions of planning, organising, leading and controlling the activities of a nursing unit. This study presents the challenges encountered by the critical care unit managers in the management of a large ICU. A large ICU refers to one that has 12 or more beds per unit.
Critical care nurses are responsible for clinical assessment, making diagnoses and designing individualised care plans for critically-ill patients in order to reach the expected outcomes for each patient. Unit managers are responsible for the effective and efficient management of the unit but, in addition, are often required to do functional nursing and fulfil other roles in relation to care of the patients. The roles and functions of registered nurses working in critical care units are regulated by the South African Nursing Council (SANC) according to the scope of practice for registered nurses (SANC 2005:R2598, as amended). Despite all their competencies, expertise and experience, there seem to be unique problems encountered by unit managers on a daily basis when working in large ICUs. The argument in this article is that it is necessary to understand the challenges encountered by the ICU managers working in the large ICUs of 12 and more beds. This will assist in the design of strategies to overcome these challenges.
'Yes we do have enrolled nurses in the unit which is also a challenge. The challenge being that enrolled nurses have their scope of practice which does not qualify them to work in the intensive care unit. But now we are expected to work with them like professional nurses and really it is a challenge'. (P3, Male)
The participants advocated that there should be shared responsibility between the unit manager and the other nurses in the unit. The major problem highlighted was with being in charge, either as the unit manager or as the shift leader. It was revealed that the unit manager had to constantly supervise whether orders were carried out and medications were in fact given at the prescribed times. It was indicated that there were several times when the unit manager did the nursing rounds; where it was found that there were nursing care and practice duties that were not carried out. The unit manager ended up being responsible and accountable for those duties.
In this study, the units had 14 to 23 beds. They had different layout and structures, alternating between open plan or private rooms (or a combination thereof) and the participants acknowledged that the different structures and layouts had both advantages and disadvantages with regard to nursing care and practice. The findings concur with Flaatten (2007:392) who indicates that the impact of the design of an ICU affects the patients, relatives and ICU personnel; and that there is also a huge need for privacy in ICU, meaning that there should be single-bed rooms available in order to allow patients and visitors privacy and also to allow the staff to perform their procedures. According to Flaatten (2007:391), an ICU can be considered as the sum of all tools acquired to treat patients, which is the way it is physically combined, how it is planned and the types of rooms that are built for the patients. It is worth noting that the design of an ICU can have an impact on the outcomes of care; and that cross-contamination and infections can be correlated with different designs. The participants indicated that they needed the units to be divided into manageable sections. According to the guidelines for ICU design, 8-10 beds per unit are considered best from a functional perspective (Rashid 2006:286). It therefore follows that the units with 23 beds could be divided into two sections, perhaps with shift leaders for the sections (over and above the unit manager).
The findings indicated that it was not possible to have competent, trained and experienced ICU nurses because of the global shortage of nurses, especially registered nurses (Gillespie 2006). According to the BACCN standards for safe nurse staffing in critical care (BACCN 2010:6), every patient in a critical care unit must have immediate access to a registered nurse with a post-registration qualification in this specific specialty. However, the shortfall in the availability of critical care nursing staff was addressed through overtime work on the part of permanent ICU nurses who were off duty or by the use of agency nurses, including the utilisation of other categories of nurses such as enrolled nurses. In the South African context, enrolled nurses are not trained to work in the ICU. Rischbieth (2006:399) indicates that some of the factors contributing to inappropriate and potentially hazardous care delivery include nurses working out of their scope of practice in the ICU. The level of care required by each patient should equate to the skills and knowledge of the registered nurse delivering and/or supervising that care (BACCN 2010:21).
This article presents to the reader an understanding of the context of a large ICU and the different challenges encountered by the unit managers in these ICUs. The findings of this study may trigger interest in the development of norms for the 12 and more bed ICUs in the country. The recommendation for future research and nursing practice is to develop and implement strategies in order to overcome the challenges faced with regard to the management of large ICUs.
Some LTCFs used ENAs to administer medication, even though there is no provision for ENAs to administer medication in terms of Chapter 6 of Regulation 2598 of 1984: the Regulations Relating to the Scope of Practice of Persons who are Registered or Enrolled under the Nursing Act, 1978 as amended (SANC 1984). The scope of practice for nurses in South Africa is currently being reviewed, although not yet finalised (SANC 2021). Certain LTCFs had no medication policies, whereas some LTCFs with policies did not specify timeframes for reading these policies. The purpose of medication policies is to guide nurses and should be readily available and regularly consulted (Lindblad, Flink & Ekstedt 2017; Vogelsmeier 2011). Furthermore, faulty policies could contribute to 6% of medication errors (Ferrah et al. 2017). The Code of Ethics for Nursing Practitioners in South Africa also confirms that nurses are accountable for their actions and omissions (SANC 2013). Although the ENAs in this study felt fairly at ease when performing drug rounds alone, they also showed the most concern for the shortage of appropriately qualified staff as a reason for medication errors. A study by Aiken et al. (2017) showed that when one RN is substituted with one ENA per 25 residents, it reduced the skill mix from 66.7% to 50%, which could lead to a 21% increase in the probability of mortality for residents. The absence of medication policies for guidance and responsibilities beyond the scope of practice of specific nurse categories could leave nurses exposed. Another concern is the exposure of the LTCFs to vicarious liability. In other words, the employer could also be held liable for the actions of their employees in terms of common law (Dhai & McQuoid-Mason 2011).
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