For example, based on your assessment:
In B.C., diagnosing (a disease, disorder or condition) is a restricted activity granted to some regulated health professionals. For instance, physicians and nurse practitioners are authorized to diagnose diseases, disorders and conditions. Registered Psychiatric Nurses (RPNs) have the authority to diagnose conditions only.
Conditions usually have associated signs and symptoms such as abnormal temperature, pulse or pain. However, in mental health there may be exceptions when the signs and symptoms may not be as readily observable, for example, internal suicidal ideation, thoughts of paranoia, or anxiety. A condition may also be the result or be related to a known disease, disorder or its treatment.
For example, an RPN may diagnose a disturbed thought process in a person who has schizophrenia, chronic confusion in a person who has been diagnosed with Parkinson's disease, hypoglycemia in a client with diabetes, or angina in a client with a history of coronary artery disease. Other conditions, such as hypoxia, or pain may result from a medical problem such as an undiagnosed disease or disorder. In these situations, an RPN may diagnose and stabilize the condition until another authorized health practitioner diagnoses the underlying disease or disorder.
In addition, there are some conditions that psychiatric nurses are able to treat to resolve, and others they are able to treat to stabilize until seen by another health professional. These 2 tables provide some examples of both.
There are four levels of control on RPN’s practice:
¹ RPNs in independent practice assume the responsibilities of employers.
The Nurses (Registered Psychiatric) Regulation provides the authority for RPNs to make a nursing diagnosis identifying a condition as the cause of a client’s signs or symptoms. In the Regulation “nursing diagnosis” means:
“a clinical judgement made by a registrant of an individual’s mental or physical condition to determine whether the condition can be ameliorated, or resolved by appropriate interventions of the registrant to achieve outcomes for which the registrant is accountable”.
It involves drawing a conclusion about what is causing the signs or symptoms you have recognized.
BCCNP RPN scope of practice standard
Autonomous Scope of Practice and Client-specific Orders consist of the following standards:
within Autonomous Scope of Practice outlines the requirements necessary for RPNs when acting within autonomous scope of practice.
What is Autonomous Scope of Practice?
‘Autonomous Scope of Practice’ includes the restricted activities listed in Section 6 of the
Regulation and the provision of other care or services that do not involved restricted activities, except for any activities, care or services that are excluded from autonomous scope of practice.
What is excluded from Autonomous Scope of Practice?
‘Autonomous scope of practice’ excludes any activity, care or services:
What’s my accountability?
When you diagnose, and decide to treat a condition,
you assume sole accountability and responsibility for the diagnosis, appropriate treatment, and your client’s outcomes. When doing so you follow a clinical decision-making process by:
Depending on the activities you are carrying out, there may also be BCCNP limits and conditions in place. For example, you may determine a client requires an intravenous infusion to manage hypovolemia. However, BCCNP has both a condition (an RPN must have additional education) and a limit (only short peripheral devices can be used) in order to perform venipuncture with or without an order.
The following documents contain additional information to support you when diagnosing and treating conditions:
How do I apply the standards for
Acting within Autonomous Scope of Practice?
Are there any limits and conditions on the activities I plan to carry out?
Organizations establish processes, supports and resources such as policies, procedures, and Decision Support Tools (DSTs) to outline expectations and support evidence informed psychiatric nursing practice when diagnosing and treating conditions and ensure that RPNs meet the standards set out by BCCNP.
These DSTs may be called:
Be aware that when you carry out any activity within autonomous scope of practice, even when following a DST, you are solely accountable.
Organization policies may also limit the practice of an RPN in a workplace setting. Before carrying out an activity within autonomous scope of practice, you’ll need to make sure it is within any restrictions set by your organization.
If there are no existing organizational policies or procedures, RPNs follow up and seek direction from the employer, clinical resource or practice leader.
RPNs only perform activities and provide care or services that the RPN has the individual competence to carry out.
RPNs clarify their roles and responsibilities in their organization when acting within autonomous scope of practice. See RPN scope of practice standard Acting within Autonomous Scope of Practice for more details.
RPNs work with other members of the health care team to provide clients with safe and effective care. Consider how you communicate and consult with others on the team. You may seek advice from colleagues or consult with listed or non-listed healthcare professionals before arriving at a nursing diagnosis, finalizing a plan of care, or determining the most appropriate treatment for a client.
Think about the clients in your clinical practice, and consider the conditions you may diagnose and treat.
Can an RPN diagnose and treat Anaphylaxis?
Mike, an RPN, can hear the two approaching even before his client, 28-year old Simon and his co-worker arrive at the nurse’s station at the mental health group home. Simon is experiencing some nasal congestion and describes how he has just been stung by a wasp while showing Mike his red, swollen shoulder.
As he sits Simon down to examine him more closely, he listens to a recounting of the event. Simon is visibly anxious, his skin flushed and blotchy and his breathing has become a little wheezy. His concern increased, he asks Simon if he is allergic to bees or wasps. Simon states he doesn't know as he has never been stung before.
Mike can see swelling beginning around Simon's mouth and his breathing becoming more labored. Checking Simon’s pulse, he finds it rapid. He’s certain Simon doesn’t have any allergies to medications – he’s reviewed his chart including his medical history and medication records and there are no known allergies listed. Mike runs systematically through his assessment – a rapid pulse, anxiety, red blotchy rash, facial angioedema and wheezy, labored breathing.
In his clinical judgment, these are signs of anaphylaxis. He knows the treatment is prompt administration of epinephrine. Deciding on his next steps, Mike calmly explains to Simon that he’s likely reacting to the wasp sting and asks his co-worker to call 9-1-1.
Can Mike treat Simon without an order?
Yes, under the Nurses (Registered Psychiatric) Regulation, Mike is authorized to diagnose and treat conditions. This includes administering Schedule I medications without an order to treat certain conditions. The scope of practice for RPNs sets standards, limits and conditions under which Mike can give epinephrine to treat anaphylaxis. The standard, Acting within Autonomous Scope of Practice, outlines the requirements for Mike when he carries out an activity within autonomous scope of practice. BCCNP further sets conditions that require Mike to have additional education and follow an employer approved decision support tool (DST).
What does Mike do?
Following the employer's anaphylaxis protocol, Mike carefully draws up the correct dose of epinephrine. He explains to Simon that he needs to give him an injection of medicine to make his breathing easier. Reassuring him that it will be quick, he talks him through the procedure.
Within minutes, Simon’s breathing becomes less labored and his facial swelling decreases. When Mike checks his pulse, he’s relieved to find that its quality has improved. Shortly after this, the ambulance arrives and Mike provides a quick report to the paramedics. While the paramedics perform their own assessment, Mike documents the incident and his actions. As Simon is loaded into the ambulance, he assures him that he will notify his next-of-kin. When the ambulance carries Simon away, Mike breathes a sigh of relief.
How is Mike meeting the standards for acting within autonomous scope of practice?
Before treating Simon, Mike assessed him, diagnosing anaphylaxis as the condition associated with a wasp sting as the likely cause of his signs and symptoms. Having previously obtained the required additional education, as set out in the BCCNP Scope of Practice for Registered Psychiatric Nurses: Standards, Limits and Conditions, he knew he could improve or resolve Simon’s condition with nursing activities – including administering epinephrine.
In deciding to treat Simon, Mike considered the risks, benefits and possible outcomes. In his judgment, the outcome was reasonably predictable and the benefits outweighed risks. He knew he had the competence to administer the epinephrine safely and manage any outcomes. He followed an evidence-based protocol/DST and knew his actions were within agency policy. Mike understood he was solely accountable for his decision to treat Simon and confident it was the right one.