Practice Expectation Spotlight: Complex Client Needs

How can you know if providing for a client’s complex care needs is within your scope of practice?

Consider this scenario encountered by an RN(NP).

Atiba Harper RN(NP) assesses a 16-year-old client with an unwanted pregnancy at a walk-in clinic. The client and their older sister insist on access to a medical abortion during the visit. When the RN(NP) takes the history, the client says that they consistently used oral birth control and they track their period with an app on their phone.

The sister is certain of this pregnancy because the client vomited shortly after taking the birth control pill on three consecutive days. The client is sure that they are exactly seven weeks pregnant and shows the data tracked on the cell phone.

Atiba uses a urine pregnancy test to confirm a positive pregnancy result. However, a same-day ultrasound to confirm pregnancy dates, is not available at this clinic.

This RN(NP) has not previously prescribed medication for abortions and is unfamiliar with the cellphone app. The client clearly shows Atiba how the app works, and notes the client’s goal of care includes same-day access to medical abortion medications. Atiba wonders if it is in their scope of practice to write the prescription given the available assessment data, the RN(NP) role in the clinic, available resources, and collaboration and individual RN(NP) competency.

What should this RN(NP) do?

If you were in a similar situation, what would you do?

In this scenario, Atiba Harper RN(NP) needs to consider, at a minimum, the following responsibilities before any decision is made in order to prescribe these medications.

Ensuring the Activity is Authorized

To determine if prescribing a medical abortion medication is within their scope of practice, the RN(NP) reviews information about the specific medications for medical abortion and notes that they are authorized to prescribe, as the medications are listed in schedule I of NAPRA (National Association of Pharmacy Regulatory Authorities). The RN(NP) knows that just because they are authorized to prescribe these medications, that does not mean they must be prescribed, as they must also consider the responsibilities below.

Competence

Atiba Harper RN(NP) has not previously prescribed one of the medications for medical abortion, however, does have competencies related to prescribing and is aware of the prescribing practice expectations. The entry-level competencies create a foundation for the RN(NP) to consider expanding their competence at the point-of-care. The RN(NP) looks for resources in their practice setting to gain competence related to these medications. When reviewing available information, the RN(NP) reflects on:

• Do I understand the evidence (indications, contraindications, risks and benefits) in relation to the medication?
• Do I understand how the medication impacts the health of clients?
• Do I understand the limits to my practice with regards to the medication and any contraindications to prescribing it within the walk-in clinic?
• Can I use the assessment data attained so far to safely prescribe? What other assessments are needed?
• How/who can I check with to ensure that my prescribing of the medication is appropriate?

If the RN(NP) is not able to attain the information needed to competently prescribe the medication, the RN(NP) needs to consult or refer to ensure continuity of safe, competent and ethical care. In cases where the client does not have alternative or timely options for care, the RN(NP) considers options such as a virtual consultation to meet the client’s needs.

Client Safety

Before any prescribing, the RN(NP) reviews the available resources and consults with other care providers as necessary, to ensure that they can prescribe the medication safely. Considerations include:

• What policies and procedures are in place at the clinic to support safe prescribing?
• Are there critical incidents/adverse events associated with the medication?
• What is the availability for client follow-up and access to urgent/emergent care if complications occur before the next follow-up appointment?
• What reproductive counselling will be offered and by whom?
• How will the client’s psychological safety/supports be addressed?

Appropriateness

Atiba understands that not all services are appropriately provided in all practice settings. To determine appropriateness, the RN(NP) reflects on if they can meet all practice expectations within the walk-in clinic when prescribing the medication. The RN(NP) considers what resources are available at this clinic as well as whether there is an employer policy that would limit prescribing this medication. If there are reasons why the medication cannot be appropriately prescribed in the practice setting, the RN(NP) is expected to articulate the rationale to the client and create a plan of care that supports access to the care given the goals and circumstances of the client, as well as the available resources.

Risks and benefits are reviewed to mitigate potential harm to a client who accesses care at a walk-in. Referral process to a tertiary health-centre where the procedures, counselling, and resources are available can also be a viable option.

To ensure a consistent standard of care for all clients, the RN(NP) shares any learnings with management and provides input into any standard procedures or protocols for clients presenting with similar health care needs.

Collaborative Practice

Atiba Harper RN(NP) considers their role within the team, the role of the walk-in clinic within the community, and availability of other resources. The RN(NP) works in partnership with the client to gather assessment data and create a plan of care that meets their needs and manages expectations within the available resources, as long as it is safe and appropriate. This also includes documenting the analysis, teaching, collaboration and other essential elements of the client’s care in the health record.

Where needed, the RN(NP) consults or refers and uses technology to provide quality care from the client’s perspective. The need for consultation and referral is also required if the RN(NP) conscientiously objects.

Summary

While you may or may not find yourself in this specific situation, this scenario demonstrates that you can apply these responsibilities to assist you to determine if any practice is within your scope of practice. So, the next time you are faced with a complex client care situation and are unsure if you can manage it within your individual scope of practice, consider the responsibilities below:

• Ensure the activity is authorized
• You can demonstrate competence in the activity
• Client safety needs can be met
• The care of appropriateness for the client
• You are meeting collaborative practice expectations in your practice setting.