Incorporating a restricted activity into practice
Andrew is a registered nurse (RN) working on a newly opened brain-injury rehabilitation unit. One of his clients who arrived on the unit two weeks ago, suffered a traumatic brain injury and is slowly progressing through his recovery. The client is unable to consume any solid or liquid food orally and is fed through his gastrostomy tube (G-tube). When providing morning care, Andrew notices that the client’s G-tube is dislodged, but not completely out. He assesses the site, stabilizes the G-tube with tape and covers it with a dressing as a temporary measure.
Andrew calls the client’s physician to let him know about the dislodged G-tube. He communicates the situation and assessment of the client to the physician, and the physician orders the G-tube to be re-inserted by the RN at the bedside. Andrew has not encountered this situation on this new unit before so he is unsure whether RNs are able to (or should) replace G –tubes.
What does Andrew do?
Based on Andrew’s knowledge about the CARNA Practice Standards for Regulated Members, he knows that he:
- Is responsible and accountable for his nursing practice at all times
- Is required to follow current legislation, standards and policies relevant to his practice setting
- Can only perform restricted activities authorized under the Registered Nurses Profession Regulation that he is competent to perform and that is appropriate for his practice setting
Andrew also knows that he is responsible and accountable to adhere to CARNA’s Restricted Activities Standards. Specifically:
- He should only perform restricted activities that he is authorized and competent to perform, and
- He should only perform restricted activities that are supported by his employer and appropriate to his practice setting.
Andrew communicates his concerns to his unit manager and asks for further direction. Given that the intervention has not been performed by RNs at the bedside on the unit, the unit manager decides to call the unit educator as well as a CARNA policy and practice consultant for further direction. In the meantime, in the absence of written employer requirements, Andrew contacts the physician to re-insert the G-tube.
Considerations for incorporating a restricted activity into a practice setting
CARNA’s policy and practice consultant refers the unit manager to CARNA’s document Incorporating a Restricted Activity into Practice Guidelines. Specifically, the consultant highlights the decision making framework to support the unit manager in determining whether the restricted activity of replacing G-tubes by RNs should be incorporated into the unit:
- Is replacing a G-tube a restricted activity that regulated members of CARNA are authorized to perform under the Registered Nurse Profession Regulation (the Regulation)?
As per section 15(1) of the Regulation, “regulated members on any register may, within the practice of registered nursing and in accordance with the standards of practice governing the performance of restricted activities approved by the Council, perform the following restricted activities: (b) to insert or remove instruments, devices, fingers or hands (vii) into an artificial opening into the body. In this scenario, the G-tube is the device and the artificial opening is the stoma.
The policy and practice consultant informs the unit manager that in order for RNs to perform a restricted activity, they must be knowledgeable, skilled and competent. In this scenario, there are no legislative barriers for RNs to replace G-tubes.
- Will the restricted activity address the health-care needs of the client?
Incorporating a restricted activity into a practice setting should be driven by the needs of clients and not by the desire for convenience of health-care professionals. In this scenario, there has been an identified need for one client on the unit.
- Are RNs the right provider to meet the needs of the client? Is there another health-care professional who is reasonably available and whose knowledge, skills and experience is more appropriate for performing the restricted activity?
Careful assessment is required to determine which health care provider is best positioned to carry out the restricted activity. The employer, RNs and other members of the interprofessional team should work together to evaluate the need for, and the performance of all interventions, including the competence of the practitioner involved, on an ongoing basis.
- Has the RN received the necessary education/training? Is the restricted activity part of entry-level competencies or is additional education/training required? Does the RN have the skills to perform the restricted activity autonomously?
If G-tube insertion is required in the practice setting, the appropriate education, orientation and staff development should be designed based on learning needs. RNs are expected to identify their own learning needs with respect to the restricted activity, practice only within their areas of competence, and utilize available educational resources to attain and maintain competency in the restricted activity.
- Is the restricted activity within the regulated member’s role in their practice setting? Is the restricted activity appropriate to the practice setting? Does the Regulated member have available facilities and equipment, clinical support tools (where required) and policies?
When deciding whether to incorporate a new intervention into a practice setting, it is important to consider the care context including the acuity, stability, and complexity of clients. It is appropriate for the unit to assess whether this will be a recurring need for other clients.
The unit manager and RNs should ensure mechanisms are in place to address gaps in skills, knowledge and competency so that the RNs can maintain competence to replace G-tubes safely and competently. Practice setting supports including the identification and establishment of policies and procedures to facilitate the safe and competent performance of the activity are required to enable all RNs to replace G-tubes safely and competently. Employer policies and procedures help support practice and identify parameters and limitations, and should be consistent with therapeutic client outcomes, current practices and safety standards.
- Is performance of the restricted activity consistent with best practice?
Evidence-based practice is providing the best possible care and making decisions based on sound clinical judgment arising from knowledge and experience. Regulated members must incorporate relevant knowledge into practice as current research findings and evidence becomes available.
The unit manager works through the steps identified by the Policy and Practice Consultant at CARNA to determine if G-tube insertion should be an intervention the staff on this unit are educated and supported to perform. Based on a review of evidence and best practices, the unit manager communicates next steps to the staff.
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.