I have been approached by a new, volunteer community health service operating in New South Wales. The organisation is ‘a registered charity that provides first aid & health monitoring services…’ The team is made up of registered nurses, an emergency medical technician and others with Occupational First Aid certificates.
During a meeting to discuss their operations, a representative from a local public hospital ‘stated that she did not believe Registered Nurses or Paramedics have the authority to use their skill set outside the NSW Health environment.’ I am asked
‘Are you aware of any legislation that prohibits Registered Nurses (employed by either NSW Health of Corrective Services) from providing care in a volunteer capacity outside the NSW Health environment?’
It is suprising that anyone could make a statement to the effect that ‘Registered Nurses or Paramedics [do not] have the authority to use their skill set outside the NSW Health environment.’ The HEALTH PRACTITIONER REGULATION NATIONAL LAW (NSW) governs registered health professionals, which includes Nurses (but not paramedics). An Act designed to establish various health registration boards, to empower that board to determine who can be registered and how they are to be disciplined if their conduct is sub-standard is unlikely to say, and does not say, that there are some limits on where those registered health professionals can work.
Further we have to consider what skills are nurses using in this context? They are trained to provide patient care, to recognise illness and injuries, to apply dressings, administer medication, use equipment like oxygen and defibrillators and other monitoring equipment, they could take a blood pressure and I’m sure many other things. None of those skills are regulated, that is anyone who knows how to do those things can do them. What you can’t do, if you are not a registered nurse, is call yourself a registered nurse and engage in some practices primarily related to dentistry (HEALTH PRACTITIONER REGULATION NATIONAL LAW (NSW) ss 113-123).
So let us think about the suggestion that nurses cannot use their skills outside their employment. Would that mean a nurse at a car accident couldn’t say ‘you need to go to hospital I can see that you have a serious injury?’ Does that mean a nurse couldn’t do CPR because they learned that in their nurse training and not in a first aid course? Merely saying that shows how silly the assertion is. A person who is a registered nurse is a registered nurse, they don’t unlearn things when they go off their shift. Of course they can use their skills and knowledge outside work unless there is some regulation to stop them.
Relevant limitations do exist with respect to scheduled drugs.
- In order to possess, use, supply or prescribe a poison, restricted substance or drug of addiction for the purposes of the practice of nursing, a nurses registration must be endorsed with specific authority or the nurse must be registered as a ‘nurse practitioner’ (POISONS AND THERAPEUTIC GOODS ACT 1966 (NSW) s 17A). ‘A nurse practitioner must not supply a restricted substance to any person otherwise than in the course of practising as a nurse practitioner’ (POISONS AND THERAPEUTIC GOODS REGULATION 2008 (NSW) r 43) but practice as a nurse practitioner need not be limited to employed practice but would depend on the terms of the registration.
- A nurse in charge of a ward in a public hospital is entitled to be in possession of and supply drugs of addiction or prescribed restricted substances (POISONS AND THERAPEUTIC GOODS REGULATION 2008 (NSW) rr 62 & 101). This clearly applies only at work, the nurse volunteer is not ‘in charge of a ward in a public hospital’ when they are ‘off shift’ and volunteering with a community service.
- There is no offence if a nurse, or anyone, takes possession of and administers a restricted substance to the person that it was prescribed for (POISONS AND THERAPEUTIC GOODS REGULATION 2008 (NSW) r 59).
Who or what is an emergency medical technician is undefined by law. Presumably they have a qualification in that name but it gives them no more, or less authority, than anyone else, but remember one doesn’t need authority to do lots of things, and use first aid equipment and skills. If you are trained to use oxygen, a defibrillator, a splint etc you can use them as there is no law to say you cannot.
A person who holds a WorkCover approved occupational first aid certificate ‘is authorised to possess and use methoxyflurane and nitrous oxide if required in connection with the carrying out of first aid’ (POISONS AND THERAPEUTIC GOODS REGULATION 2008 (NSW) Appendix C, clause 9).
In short nurses are nurses and have been volunteering to provide nursing care across the community for many, many years. To suggest that they cannot use their skills and knowledge is just, to put it bluntly, silly. The limitation that does exist is in the possession of and use of drugs. They cannot carry restricted drugs, no matter how well trained and experienced they are, outside their employment unless that is endorsed or their registration and subject to that endorsement that is unlikely to extend to their volunteering in this context.
The fact that the nurse is a nurse and is providing care means that the care that they deliver has to meet the standard expected of a reasonable nurse in the circumstances. That would be the standard in any civil litigation alleging negligence and would be the gist of the issue should there be a complaint of unsatisfactory professional conduct or professional misconduct.
An organisation that uses volunteer nurses should of course ensure that either the organisation or the nurse has adequate professional practice insurance. An organisation providing a first aid service should also be mindful of the provisions of the Health Services Act 1997 (NSW) s 67E that makes it an offence to provide an ambulance service without the permission of the Director General of Health.
Very interesting read Michael.
I would be interested to know your thoughts on these types of nurses performing invasive procedures that do not include restricted drugs. Eg IV cannulation for fluid therapy, Laryngeal Mask Airway etc.
Ben, if they are trained and competent to do so, and it’s required, there’s nothing to stop them and they should do it. Imagine if you go to a first aid post and there’s a registered nurse there, who has the skills to administer what you need, and the equipment’s there and they don’t do it? The harm is much greater than any potential harm in not doing it and if someone doesn’t act when they could because of their own fear, they probably shouldn’t be there. Ethical practice requires them to advance the patients needs, not their own, subject to the law but the law doesn’t restrict who can do these procedures, provided you know how and the patient consents.
Thanks for the response Michael.
I think the biggest cause for concern in this area is the lack of clinical governance that is in place in these ‘first aid’ settings. There is generally no onsite physician, no genuine medical board, no medical director and no clinical practice guidelines overseeing and reviewing these invasive procedures like there is in a hospital or legitimate health service environments.
My concern would be that the organisation permitting the nurses to perform these procedures without clinical governance would be open to litigation for operating an un-authorised health or medical service as these interventions would fall out of the ‘first aid’ scope.
Ben, I think you’ll be suprised just how unregulated this area is and there is no offence of providng an ‘un-authorised health or medical service’. The list below is the list of offences from the HEALTH PRACTITIONER REGULATION NATIONAL LAW (NSW)
Division 10 – Title and practice protection
Subdivision 1 – Title protections
113. Restriction on use of protected titles
114. Use of title “acupuncturist”
115. Restriction on use of specialist titles
116. Claims by persons as to registration as health practitioner
117. Claims by persons as to registration in particular profession or division
118. Claims by persons as to specialist registration
119. Claims about type of registration or registration in recognised specialty
120. Registered health practitioner registered on conditions
Subdivision 2 – Practice protections
121. Restricted dental acts
121A. General anaesthesia and simple sedation in dentistry [NSW]
122. Restriction on prescription of optical appliances
123. Restriction on spinal manipulation
Provided you don’t call yourself a doctor, or nurse, or one of the other registered health professionals (whcih does not include paramedic) then you’re not comitting an offence. It may be negligent to hold yourself out as having skills you don’t have, but you can in fact perform various skills, quite competently, without registration so negligence isn’t axiomatic.
What’s within the scope of first aid is up to the first aid providers to determine. What’s taught in a two day first aid certificate may be a minimum standard, but one can provide more, there is nothing to stop me setting up Michael’s Paramedic Service and offering a myriad of advanced life support service. I couldn’t use scheduled drugs but there’s nothing to stop me providing other invasive service.
Nurses can do any number of these procedures as they know how to do them,whether you need all those clinical governance standards is a question of risk assessment and compliance with industry norms if you want to defend your practice, but they’re not required by legislation.
A couple of very interesting articles on the subject…