Interpretation of the scope The aim of this paper is to describe, with practical
examples, the professional-ethical responsibilities of the
of practice of the South South African GGN. These responsibilities, in terms of the
Scope of Practice (South African Nursing Council (SANG)
Regulation 2598) as amended,2 regulate the practice of the
African critical care nurse registered nurse in South Africa These are not
specialisation-specific and are not always well understood
J. Scribante, M. E. Muller, J. Lipman by the practising GCN. It is also very important that all
members of the critical care team understand and
appreciate the professional-ethical responsibilities of the
GriticaJ care is a constantly evolving discipline. The aim of
this paper is to describe the professional-ethical
responsibilities of the South African critical care nurse
(CCN). These responsibilities, outlined in the Scope of
Practice (South African Nursing Ccuncil Regulation 2598), Interpretation of the Scope of
are not speciaJisation-specmc and are not always well Practice
understood by the practising CeN. The regulation consists
The description of a profession's scope of practice is very
of 20 responsibilities, including supervision and
difficult.. Anything that is left out automatically falls outside
maintenance of bodily mechanics, oxygen supply. acid
the scope of practice. It is not advisable simply to list a
base status, fluids and electrotyte levels of patients. In this series of procedures.'
paper each of these 20 responsibilities are used, with To assist in the critical care patient's return to health, the
practical examples, to explain in detail the role of the GCN engages in the nursing process, a methodology
CCN and the importance of this role in total patient through which critical nursing care is provided. It includes
management As the discipline of critical care develops assessment, planning, implementation and evaluation as
continued and interlocking actions. Crucial decision-making
further the responsibilities of the CCN must adapt
is reqUired in the various steps of the nursing process.
accordingly. This paper provides a framework for such
The authors have interpreted the Scope of Practice
adaptation. It is only with the full understanding of (R2598) as amended' for the South African CCN. Each point
professional--ethical responsibilities by aJl members of the will be discussed with a short explanatory note illustrating
critical care team that the professional-ethical how the CCN is involved.
responsibilities of the CCN can be appreciated and utilised The interpreted Scope of Practice is as follows:
S Afr Med J 1995; 85: 435-439.
(a) 'The diagnosis of a health need and the
prescribing, provision and execution of a nursing
regimen to meet the needs of a patient or a group
of patients or where necessary, by referral to a
AI1y nationaJly registered profession requires a description of registered person. J
fts scope of practice to ensure that only persons registered
The CCN is responsible for nursing the patient, 24 hours a
in that profession are permitted to conduct the actions
day. This intense involvement places her in the position
related to n. Description of the scope of practice indicates
where she is often the first to detect a change in the
how far a specific profession can expand legally.'
patient's condition. The GGN should have the ability
There are many unavoidable overlapping or grey areas (knowledge, skills, values) to make a correct nursing
between the professions, especially between the health diagnosis, and prescribe, provide and execute a nursing
professions. The problem is addressed in that the regimen. If necessary in view of the patient's condition the
practitioner never purports that she practises a profession
CCN should report to another registered person, such as a
that she is not registered in. Both the critical care nurse medical doctor or a registered GCN. Diagnosis is made
(CCN) and the physiotherapist will perform bronchial toilet within a whole-person framework of body, mind and spirit,
on a mechanically ventilated patient, for example, but for the
but focusing on the body.
CCN this is a nursing action and for the physiotherapist it is
a physiotherapy action. In these situations each profession
(b) 'The execution of a programme of treatment or
has unique competency in its own practice domain.!
medication prescribed by a registered person for a
(c) 'The treatment and care of and the
Nursing Department., Rand Afrikaans University, Johannesburg administration of medicine to a patient, including
J. Scribante. RN.. u..CUfl (PROF Nt..I'lSINGl the monitoring of the patient's vital signs and of
his reaction to disease conditions, trauma, stress,
M. E. Muller. RN_ f..·m (PflOf MJRSINGl
anxiety, medication and treatment.'
Department of Anaesthesia, University of the Witwatersrand,
The CCN should have in-depth knowledge of the
programme of treatment to be executed or the prescribed
J.lipman. MA aa-t. CA. FCA. FFA (CRIT. CARE)
medication. She should know how the treatment or the reason for this inappropriate reading - for example, is
medication is going to act in a critically ill patient, because the transducer at the correct level?
the action might differ from that in less ill patients. For
example, the dose of certain antibiotics should be adjusted (d) 'The prevention of disease and promotion of
according to the individual patient's needs. A patient in health and family planning by teaching and
acute renal failure may need a smaller than standard dose, counselling individuals and groups of persons. '
whereas a patient with an increased third-space loss. as in This concept is not always associated with the high-tech
septic shock, may need a bigger than standard dose to critical care situation, but the critical care unit is one of the
achieve an effective serum level of the antibiotic. The ideal situations to prevent disease and promote health and
indications, interactions and complications of medicines and family planning. The patient and those close to him usually
the treatment of adverse events should all be part of the trust the CCN and respect her abilities; this promotes
CCN's knowledge base, before the programme of treatment confidence, which is essential for counselling and teaching.
is executed or prescribed medication is given. If the People confronted with critical illness go through various
registered person who prescribed the treatment or stages of acceptance. The CCN should be sensitive and
medication makes a mistake. and the CCN who executes guide the patient and significant others accordingly. For
the treatment or gives the prescribed medication does so example, if the patient who has just had a myocandial
without questioning the prescription. she and the registered infarction has difficuny accepting his new physical state,
person are both accountable for the wrong action. The attempts by the CCN to educate him in the 'do's and don'ts'
regulations do not specify or limit any route of medication of his future might have a negative effect; she should rather
administration; however, the CCN should have the ability be gUiding the patient towards accepting his new physical
(knowledge and skilQ when medication is given via a specific state. Very often the patient is susceptible to guidance and
route. Until recently it was not within the scope of practice teaching to prevent further complications of disease and
to administer medication epidurally, but in 1993 the SANC promote health. The opportunity to promote family planning
issued the following policy statement=' on epidural pain does not often arise, but should be utilised when applicable
control by the registered nurse and registened midwife: - for example, women with pregnancy-induced
'SANC views epidural analgesia as part of the registered cardiomyopathy should be advised not to fall pregnant again.
nurse's scope of practice. If the epidural analgesia is
administered by the critical care nurse she should have the (e) the prescription, promotion or maintenance of
necessary knowledge or competence and is accountable for hygiene, physical comfort and reassurance of the
her acts and omissions.' patient. '
Monitoring the critically ill patient's vital signs, both
(f) 'The promotion of exercise, rest and sleep with
invasivety and non-invasivefy, comprises an important part
of the CCN's direct patient care function. Vrtal sign a view to healing and rehabilitation.'
monitoring is one of the most dynamic fields in criIicaJ care To maintain hygiene in a crilicaJly ill patient can pose
units, with constant development of new technology. n is the numerous problems. Hygiene needs, although a basic health
CCN's responsibility to gain the necessary knowledge and need, can only be met by a highly skilled CCN with the
skill to use new technology safely. Furthermore, the CCN necessary insight into the nature of each patient's particular
should know the advantages and limilalions of invasive and condition. The CCN should monitor the vital signs and look
non-invasive monitoring methods. ft is now known that out for a sudden change from baseline in the course of a
blood pressure, which was so important for many years in procedure.
the criticaJ care unit, has a vast number of limitations. For Physical comfort, rest and sleep are heaJth needs that are
example, the way arterial blood pressure is measured poses difficun to satisfy in the intensive care setting. High-tech
a problem if there is a difference between non-invasive and treatment methods can cause severe physicaJ discomfort.
invasive measurement readings. Blood pressure is a product An empathetic CCN who explains the necessity of the
of flow and resistance and does not always reflect the treatment can make the discomfort more tolerable. A patient
body's needs. Measurements of regional blood flow, such as who knows how important the intra-aortic balloon pump is
gastric tonometry, may be of far greater value. It is policy in in assisting his heart, and what complications will arise if he
certain units to monitor vital signs on an hourly basis, but if bends his legs, is likely to be more willing to keep his legs
the patienrs condition is unstable, vital sign monitoring straight in spite of the discomfort. The CCN can undertake
should be done according to the patient's individual needs various actions to ensure physical comfort, for example
and be reflected in the patient's reconds. securing an endotracheal tube in such a way that tension to
Accurate reconding of changing vital signs is essential. n is the nose or mouth is minimised, and by asking the doctor to
also important that the patient should be assessed prescribe medication to improve physical comfort. PaIienIs
holislicaJly - he is not jUst a blood pressure or a pulmonary in the critical care unit often complain of lack of sleep and
capillary wedge pressure. Individual parameters should be rest. The severity of their illness requires these units to be
evaluated within the total clinical picture. For example, if the planned in a way that is not conducive to the individual
pulmonary artery capillary wedge pressure is suddenly patient's privacy. There is always a certain noise level, and
unexpectedly low, immediate therapeutic action should not no distinguishing between day and night, and as far as the
be taken - assess the patient's clinical state as a whole, patient's condition permits, the CCN must ensure privacy,
and if this low pressure is in keeping with the total clinical control noise and take measures such as dimming lights at
picture, undertake the appropriate action. If not, determine night.
Volllmt 85 NQ.5 M"1'995 SAMJ
(g) 'The facilitation of body mechanics and the The GGN should have in-depth knowledge of the various
prevention of bodily deformities in the execution types of ventilators and modes of ventilation used in her
of the nursing regimen. J specific unit, and be skilled in their use. The patient
The facilitation of body mechanics includes actions such receiving mechanical ventilatory support should be assessed
as positioning the patient to ensure adequate at least every hour. Assessment should include the patient's
haemodynamics. If the blooc pressure is very low the own respiratory parameters as well as the ventilatory
patient will be placed in a supine position. The patient who parameters. The importance of ventilator alarms cannot be
needs mechanical ventilatory support for unilateral lung over-emphasised. Alarms should be set according to the
disease will be nursed lying on the healthy lung to ensure individual patient's needs, and ventilator alarms should be
that it receives the maximum benefit of the mechanical attended to when triggered. It might be necessary to restrain
ventilation. Gas moves to the area of less resistance, and by a patient receiving mechanical ventilation to prevent a
correct positioning oxygen will go to the areas where it is catastrophic event, and if so, this should be prescribed by a
most needed. A patient receiving full mechanical ventilatory medical doctor and should be pertormed in the most
support is nursed as flat as possible to enhance the humane way possible to ensure the patient's dignity.
ventilationlperfusion ratio. As soon as the patient is being Oxygenation of the patient can be improved by
weaned from mechanical ventilatocy support he should be pertorming the appropriate physiotherapy and bronchial
put in Fowler's position, as high as his condition allows, toilet procedures. The patient should be mon~ored dUring
again to ensure an optimal ventilationlperfusion ratio. When the whole procedure, and in particular the oxygen saturation
body mechanics are impaired by technology, the GGN must should be measured by non-invasive pulse oximetry. Pre-
take action. The intubated patient, for example, cannot oxygenation before bronchial toilet has become a standard
protect his own airway. The CCN ensures a protected airway procedure.
by inflating the endotracheal tube to safe pressures and There are various respiratory and ventilatory parameters
monitoring these pressures regularly. that should be assessed by the GGN, but these fall outside
Critical care patients might receive muscle relaxants, or the scope of this article. In the evaluation of ventilator and
just be immobile for long periods of time. Bodily deformities respiratory parameters, a mistake often made is to assume
can be prevented by turning patients according to their that an arterial blooc gas level is the gold standard of
needs, performing passive exercise, ensuring that the eyes assessing respiratory function in the critically ill patient.
are kept moist and closed when patients cannot do this When rt is difficutt to maintain mechanics of the patient's
themselves, and reducing tension on endotracheal tubes as ventilation, for example in asthma, Guillain-Barre syndrome
previously described. and organophosphate poisoning, assessment of peak flow
or vital capacity is of much more relevance.
(h) 'The supervision over and maintenance of a The GGN can maintain oxygen supply to the tissues by
supply of oxygen.' ensuring maintenance of an adequate cardiac output by
Searle' has made ~ clear that oxygen supply does not manipulating fluid or inotropic support according to the
only mean artificial oxygen supply, but includes oxygen individual patient's needs. Oxygen demand of, and oxygen
supply to the tissues in all situations. The GGN should have supply to, tissues and imbalance of these contribute to the
the necessary ability (knowiedge and skills) to supervise and patient's compromised state. This can be influenced by the
maintain patients' oxygen supply. CCN in various ways, from the correct administration of
An open airway should be obtained by pos~ioning the prescribed medication and therapeutic procedures to
patient in the best way that his physical cond~ion permits. keeping the patient on bed rest and ensuring a peacefUl,
As far as possible the GGN should anticipate that the patient qUiet environment, thereby decreasing oxygen consumption.
is going to need artificial airway support and should do The GGN should mon~or the patient's haemoglobin
everything practically possible to get medical help. When a concentration, which reflects the oxygen-earrying capacity
natural airway can no longer be maintained and no medical of blooc. Blooc transfusion was preViously used to
help is available, the patient should be intubated correctly supplement low haemoglobin levels; today there is
and, if there is extreme airway obatruction, an emergency controversy about ~s safety, and the oxygen-earrying
tracheostomy should be pertormed. capacity of transfused blooc is questioned. Tourniquets
Effective ventilation can be assured by positioning as should be used with the utmost caution.
described under (g) above.
When ventilation is supported by the use of an oxygen
(i) 7he supervision over and maintenance of flUid,
electrolytes and acid base of patients.•
mask, certain important principles should be taken into
account. When the patient is breathing normally the (m) 'The supervision over and maintenance of
prescribed oxygen flow supply to the mask should be elimination by a patient.'
adequate. The patient in respiratory distress often needs a
The GGN should be able to assess hydration status
very high flow of oxygen because a distressed breathing
clinically and with the available technology. The fluid status
pattern 'pulls' extra room air into the mask, thereby diluting
of very ill patients is critical and the fluid balance shouid be
the fractional inspired oxygen concentration. The holes on
accurately calculated daily but also on a cumulative basis.
the oxygen mask should never be covered. When a patient
Electrolytes and acid base status should be assessed
w~h an oxygen mask is eating, pertorming mouth care or
according to the patient's individual needs. The GGN should
shaving, the oxygen mask should always be replaced by
have the ability (knowledge and skilQ to make a nursing
diagnosis when an electrolyte or acid base imbalance
SAMJ Volume 85 No. 5 May 1995
occurs and should undertake emergency measures to of the utmost importance that the selected antibiotic be
correct these imbalances, which can be life-threatening. given in the correct way to ensure adequate serum levels
Elimination should be monitored, and the CCN should and optimal pharmacokinetics. Dosages of certain
undertake the necessary nursing action to ensure antibiotics should be evaluated during the course of
elimination. treatment by determining serum levels. In this way patients
with renal impairment will not receive too high a dose and
(j) 'The facilitation of the healing of wounds and those with a third-space loss will not be under-dosed.
fractures, the protection of skin and the
maintenance of sensory functions in a patient.' (I) 'The facilitation of the maintenance of nutrition
This includes effective wound care. The CCN should be of the patient. '
knowledgeable about the most current wound care that will Nutrition of the critically ill patient is of the utmost
enhance wound healing. Prevention of wound infection is of importance. Research in this field is very difficult, but there
the utmost importance, and will include an effective infection is increasing evidence that patients should be fed as quickly
control programme in the critical care unit. Fractures should as possible. It is better to feed the patient enterally than
be immobilised effectively. The CCN should understand the parenterally, for it is more natural and there is a lower risk of
principle of orthopaedic traction to ensure effective complications.
immobilisation. Correct positioning of the patient to prevent When enteral feeding is chosen, patients can be fed
nerve and skin damage is important. The correct position continuously or with bolus feedings. Different feeds are
and the frequency of position change should be determined available, none of which has been proved to be superior.
by the individual patient's needs and physical condition. Whichever feed or method of feed is chosen, the CCN
The CCN should ensure that the critically ill patient should know the advantages and disadvantages involved. If
receives basic nutritional support that will provide essential the patient is going to receive long-term enteral a1imentation,
minerals, proteins and vitamins for the healing process, the a thin, soft nasogastric tube should be considered. Its
protection of skin and the maintenance of sensory functions. correct position should be monitored while it is in place.
Absorption should be checked according to the unit's policy.
(k) 'The facilitation of the maintenance of bodily Bolus alimentation should be given after bronchial toilet,
regulatory mechanisms and functions in a patient.' and endotracheal cuff pressure monitoring should be done
The bodily regulatory mechanisms that most critical care with the patient in a slightly elevated position, if his
patients need to maintain, regardless of their underlying condition permits.
disease, are homeostasis of fluid, cardiovascular, respiratory, Total parenteral alimentation is more expensive and
renal and gastro-intestinal systems, and enhancement of involves more risks than enteral feeding, but it has definite
natural defence mechanisms. advantages for selected patient groups. The CCN should be
This statement encompasses many of the basic principles aware of the complications involved and should take the
of critical care. Owing to its vast scope it will be illustrated necessary nursing actions to prevent them. The speed of
by the sketch of a specific scenario. A patient with intra- infusion should be monitored hourly. The increased viscosity
abdominal sepsis develops septic shock and is admitted to of the parenteral a1imentation might cause the infusion pump
the critical care unit. The aim of critical care management, not to function optimally. A slow infusion will result in the
both medical and nursing, is to maintain body functions and patient not receiving enough glucose. On the other hand, a
regulatory mechanisms both naturally and artificially until the too rapid infusion of glucose is detrimental to the unstable
primary insult resolves. critically ill patient, because increased insulin secretion may
Respiratory function will be maintained by a mechanical lead to a period of low blood glucose, especially if the
ventilator. The mode of ventilation may vary from alimentation completed is premature and hours pass before
uncomplicated volume control to complicated pressure- the next day's parenteral feed is commenced.
controlled ventilation with inverse ratios and high fractional Total parenteral feeding should not be stopped abruptly
inspired oxygen levels. These will be selected to satisfy the when enteral feeding is going to be commenced. A 1- or
individual patient's respiratory needs appropriately. 2-day period of overlap to ensure that the patient is
It is of the utmost importance that cardiac output should tolerating the enteral feeding may solve many problems.
be maintained to ensure adequate blood flow to vital organs. The CCN should be aware of clinical situations such as
This can be done either by administration of vasa-active renal failure which necessitate specific dietary limitations.
medication or by fluid therapy, according to the patient's
individual needs. The disease may cause a decrease in (n) 'The facilitation of communication by and with
blood flow to the gastro-intestinal tract as reflected by the a patient in the execution of the nursing regimen. '
intragastric mucosal pH, which may lead to translocation of Patient records are vital communication instruments in the
bacteria and bacterial products, a vicious circle in the septic critical care unit, but the CCN should be aware of other
shock process and a bad prognostic sign. The methods of communication. The patient himself
cardiovascular status may therefore be evaluated by cardiac communicates with the critical care team, sometimes very
output measurements in conjunction with intragastric subtly, and the CCN should be receptive to this. Being a
mucosal pH by gastric tonometry. good listener, giving clear explanations, consulting with the
The choice of antibiotic will be influenced by the critical patient and family, and the 'meaningful touch' improve
care unit's antibiotic resistance profile and the laboratory interpersonal relationships and are communication skills that
sensitivity report on any tissue cultured from the patient. It is every CCN should obtain.'
Volumr 85 No.5 May 1995 SAMJ
(o) 'The facilitation of the attainment of optimum It is important that the CCN adheres to this policy to
health for the individual, the family, groups and safeguard her from possible legal problems. Although her
the community in the execution of the nursing focus is on the physical health needs of the critically ill
regimen.' patient, critical care nursing should accommodate the
To ensure that optimal health is attained in the execution whole-person approach of body, mind and spirit.
of the nursing regimen the CCN should be aware of recent
research, implement research findings and undertake
research to ensure high-quaJity nursing.
(p) 'The establishment and maintenance, in the The Scope of Practice (R2589) regUlates the practice of the
execution of the nursing regimen, of an registered nurse in South Africa. This regulation is not
environment in which the physical and mental specialisation-specific and should be interpreted for the
health of a patient is promoted.' different nursing specialisations. The authors are of the
This function entails all the activities relevant to the control opinKJn that the interpretation of this regulation for critical
of the patient's situation, his environment, his nursing care nursing would be of value for the CCN, critical care
regimens, his care and record keeping.' managers, Mors and all members of the intensive care
(q) 'Preparation for and assistance with operative, In the management of the critical care patient it is
diagnostic and therapeutic acts for the patients. J sometimes vital to make crucial decisions before the
Operative, diagnostic and therapeutic acts in the critical situation becomes critical. Some of the authors'
care unit such as the insertion of an intercostal drain or a interpretations might be contentious, but this will reflect the
pacemaker are often life-saving. It is of the utmost previously referred to 'grey areas'. While it is sometimes
importance that the CCN should have the necessary necessary to make critical decisions to prevent catastrophe,
knowledge and skills to assist in these procedures. If new it is important to remember that although the CCN
diagnostic and therapeutic acts are implemented, it is her undertakes these interactions as a nursing sister and not as
responsibility to obtain the skill and knowledge required to a medical doctor, like a doctor she must take full
assist in these procedures safely before an emergency responsibility for all actions undertaken. The problems
situation occurs, for example, continuous vena-vena- posed by the 'grey areas' in critical care patient
haemofittration. management can be addressed to some extent by standard
policies in each unIT.
(r) 'The co-ordination of the health care regimens It is important to note that the interpretation of this
provided for the patient by other categories of regulation is dynamic and should be re-interpreted as the
health personnel. ' practice of critical care evolves in order to ensure that the
This is a very important professional function of the CCN, patients receive quality care.
for various health personnel are involved in the treatment of
the critically ill patient. One doctor can order a diuretic while This paper is part of a M.Cur. dissertation entitied: 'A South
African critical care patient classification system', submitted to
another can order a fluid challenge on the same patient.
the Nursing Department, Rand Afrikaans University, and
Proper co-ordination of the health care regimens guarantees
presented in part at the 1994 Southern African Critical Care
high-quality care. The CCN should be aware of and point Congress.
out discrepancies and even challenge such orders.
(s) 'The provision of effective patient advocacy to 1. Searle c. Profeuionele Praktyk: 'n Suid·A!riktiiilllSff VerpleegpetSpektief. 1s1 ed.
enable the patient to obtain the health care he Durban: 8ut1efWorth, 1987: 188·208.
2. South Atncan Nur$ing Council Regu/etJon 2598: Reguhluons RNting to the
needs.' Scope of Pracrice of PersOM Who Are Registered or EnroI.ltKJ Under the Nur3ing
Act '978. Pretona: South African NUl'Slng Council. 1991.
The CCN is the member of the health team who is in the 3. South Afm;;an Nursing CQurw;:JI. Epidural pain control by the regl$t-.d nurse and
r8glstef'ed midwife. NUfSIIIg News 1993; H(8); 11.
best position to be the patient's advocate. This entails
ensuring that the patient's human rights are respected, and Accepled 8 Feb 1995.
being a spokesman to make sure that his heatth needs are
met The CCN should at all times be self-assertive but
(t) 'Care of the dying patient and the care of a
recently deceased patient within the execution of
the nursing regimen.'
The CCN should be able to give death guidance to the
critically ill patient and significant others when specialised
facilities for such guidance are not available. The South
African popUlation has many cultures. The CCN should
know and be sensitNe to their various practices with regard
to the dying patient and the dead body. Every unit has its
own policy for the nursing action involved in this situation.
SAMJ Vollolmt 85 No. 5 MtlTI995