Today’s question again raises the issue of scope of practice so will revisit issues discussed in earlier posts – see Scope of practice – previous posts explained (January 21, 2017) and the posts referred to there.
In this case my correspondent is a medical student with St John Ambulance (but he asks me not to mention the state). My correspondent says
… healthcare professional students are told to work strictly by the first responder code of practice. This extends to the point that students cannot conduct a clinical history or examination, or use essential examination equipment, such as a stethoscope or a BP monitor.
Leon is a final-year paramedicine student and first responder. During a SJA event, he meets a patient, John who presents with a headache, neck stiffness, and sensitivity to bright lights. John is treated by a senior first responder and is given paracetamol for the headache.
As a paramedicine student, Leon is aware that these are possible signs of meningitis, and would like to escalate this by calling the ambulance. However, the first responder feels that Leon should not be diagnosing conditions in SJA, and reminds Leon that he should follow his scope of practice within SJA.
Leon is concerned that the patient has been inappropriately discharged back to the event.
This has caused a lot of issues. Students often find themselves in situations where they want to conduct a clinical assessment to rule out or rule in severe clinical conditions, yet are forbidden to do so by the organisation. Students are thus concerned that they are not providing a reasonable level of care, and by following current guidelines, are negligent in their practice. The ethical dilemma occurs as well, where students feel very uncomfortable at duties knowing that they haven’t ruled out severe clinical conditions (“Red Flags”).
Personally, I feel that students should be allowed to practice in a wider scope as long as they are competent to do so. I have argued that competency can be assessed by selecting penultimate and final year medical students who have a good level of clinical experience. Furthermore, unlike providing medications/treatment, the risk that the patient may suffer a bad outcome is low.
I would love to hear your thoughts about whether students should be permitted to conduct clinical assessments.
This shouldn’t be an ethical issue. The only concern should be ‘what is in the patient’s best interests?’ If we consider the example of Leon – what happens if Leon calls an ambulance and the patient doesn’t have meningitis? Well that’s expensive and perhaps embarrassing but no great harm done. The patient is committed to going to hospital and another opinion, for the paramedics is obtained. If the patient does go to hospital it’s because the paramedics also think that’s a reasonable response to the symptoms – all good. What if Leon can’t act and it is meningitis?
For the senior first aider in this scenario to ignore the suggestion of a health care professional student is unethical; as it would be unethical to ignore the comment from another first aider. If the first aid post is operating only on rank – I’m senior to you so I get to say what happens and I don’t have to listen to you – it’s unprofessional and not focussing on the patient’s best interests. So if another first aider says ‘hang on ….’ Everyone should stop and listen. And if that person is a health care student they should also be listened to, as the focus should be on patient care.
As for doing a patient assessment and using a stethoscope or a BP monitor one doesn’t need a licence or authority to use them, you just need to know what you are doing. But you need to think why you’re doing it. As a paramedic or doctor (or student of either profession) you may want to know a person’s BP because you are providing on-going care (so a GP wants to keep track of the persons BP) or you’re trying to make a definitive diagnosis, or if the BP is low there is something you can actually do about it. As a first aider where there will be no on-going care and nothing to suggest BP is an issue or even if it is, it’s not going to change what you do, then taking the BP (or getting out a stethoscope) is just pretentious. But if it’s important and is going to lead to better patient outcomes, and you know what you’re doing, why shouldn’t you do it? What harm can you do?
As for students of the registered health professions they are subject to professional regulation. The Health Practitioner Regulation National Law 2009 (Qld) (which has been adopted in all Australian states and territories to give rise to national registration of medical practitioners, nurses and 12 other health professions with paramedics to be added shortly) provides for the registration and supervision of students.
Students who claim expertise and try to perform skills they don’t have, may be subject to professional censure. But so will students who genuinely believe that there is an issue that is being overlooked but say nothing as they are more concerned about the reputation of the agency and less about the patient’s wellbeing.
In the example given, Leon needs to step up and talk to the patient and his colleague. And if he really believes it’s necessary, call an ambulance.
Certainly should complete a full assesment with the available tools in their backpacks and then with the evidence recorded suggest to the Pt that he should go to his GP or hospital or here in WA to an SJA A&E. At least with the assesment and recorded done both First Responder and Student should have peace of mind as they are not yet Drs or Paramedics.
In this scenario, there can be little downside to the HCP student calling an ambulance. I think the real question behind the stated one is obscured by the scenario here. If the HCP student exceeds his or her scope of authority as specified by SJA (despite having additional training or knowledge), and treats a patient with deleterious consequences (despite otherwise not being negligent), surely the HCP student and vicariously SJA have some liability and not be protected by good Samaritan legislation? Are there any circumstances where exceeding the scope of authority from your employer is acceptable from a liability point of view?
I’ve read your 21 January post which addresses my comment. In particular, I like your conclusion that “And if you’re a registered health professional and you seriously think that if it came down to a matter of life and death the organisation would prefer you to let the patient die than do something that you are qualified and competent to do, you need to rethink your volunteering.”