Recently, I had an encounter with the family of the patient. Several family members were in the medical field and unfortunately, they were not happy with the care their loved one was receiving. They felt like the nurses were too slow and they had to wait for the nurses to get orders for over the counter medications. I explained that every medication we give, even if it is over the counter, requires a physician order. They responded by asking why the RNs weren’t practicing to the top of their licenses. I thought this was an interesting question and sought to examine the practice of my nursing staff. First, though, is to define it.
Practicing to the top of a license is a term we hear often now. What does it mean exactly? There are several definitions. Katherine Virkstis of the Advisory Board defines practicing at the top of a license as practicing to the full extent of one’s education and training. She goes on to say that nurses should not spend their time doing something that someone else can do effectively. Does this definition give RNs permission to refuse to do patient care tasks that they consider menial such as taking vital signs or giving a bath? As a nurse leader, I sometimes witness staff “delegating” tasks they consider to be beneath them. Nurses define for themselves which tasks are menial and which are not. Those “menial” tasks are important opportunities for assessment and developing caring relationships with patients.
In an article related to physician’s practicing at the tops to their license, Jennifer Adaeze Okwerekwu, describes the challenges of physicians who find themselves doing non-medical care rather than direct patient care. Okwerekwu states “As a doctor, I’m training to be at the top of the hierarchy….”. Once again, we are looking at differences in levels of practice as hierarchical and elitist rather than complimentary.
Another definition of practicing to the top of one’s license by Stephanie Allen is minimizing non-value-added (NVA) work which are tasks that do not “directly benefit the patient and are not necessary to delivering care”. She lists some of the NVA work as looking for equipment, waiting for phone calls and similar tasks. There are other non-licensed support staff that can answer the phone and look for equipment. I prefer Allen’s definition of practicing to the top of one’s license because it emphasizes value-added work, focuses on the patient, and doesn’t feel elitist. It is important to recognize that each member of the team has an important role that is essential to the care of the patient. Allen recommends several strategies to promote value added work in nursing which include reviewing nursing scopes of practice to ensure we aren’t inhibiting nurses from top of license work. Many times, tradition and ritual define our practice rather than actual scopes of practice.
When looking at nursing practice, it is important to make sure that we are maximizing our time doing patient care and building relationships with patients. It is also important to be sure that we are sensitive to the all the members of the care team and value everyone’s contribution rather than promoting an elitist stance.