Interpreting Direct Supervision: Be Careful!
Lynn Power, RN, MN
Nursing Consultant - Practice
Direct Supervision is defined as having " a competent individual immediately present to direct and guide performance
of an activity and to regulate, manage, evaluate performance
or follow-up on performance (ARNNL: Competencies
Required by RN's for Entry to Practice, 1998). An individual
is considered to be a competent supervisor if he/she has the
necessary knowledge, judgment, attitudes, and skills, as well
as the authorization to provide supervision.
There are three situations where the direct supervision
clause is used in nursing:
Š Performing roles that are recognized to be within the
scope of nursing practice,
Š Performing non- nursing roles during emergent or
urgent situations, and
Š Performing non-nursing roles during routine situations.
Only the first two are acceptable practice!
The first situation arises when you asked to perform an
activity that is within the scope of nursing but you are not
yet proficient in performing. The scope of nursing practice
is broad and defined as the range of roles and functions that
you are educated and authorized to perform (ARNNL,
1995). Education includes both your initial RN /BN training
and continuing educational endeavors. Although ARNNL
has identified some boundaries, e.g. non-delegated medical
functions, authorization to perform most nursing acts primarily rests with your employing agency, which is often
outlined in nursing policy. Therefore although there is no
set "list" of skills there are mechanisms to determine if an
activity is within your scope.
In this first situation direct supervision allows you an opportunity to work to your full scope by gaining experience in
different nursing acts without jeopardizing the safety of
client care. For example, your first vaccination clinic or the
first time you cared for a client with a tracheostomy.
The second situation occurs when you are asked to perform
an activity outside of your approved scope of practice, however the situation calls for emergent or urgent action on
your part. Nurses commonly operate under direct supervision in emergencies such as a cardiac arrest. You can also
perform activities under direct supervision during urgent situations often described as situations where a third hand is
required to safely and competently provide client care. For
example, while inserting a scope or drain a physician experiences difficulties and asks for assistance with administration
of select drugs such as anesthetic agents. Both of these situations involve unanticipated events. Performing activities
under direct supervision in these situations is acceptable
practice as long as you abide by agency guidelines. Policies
4
about assist roles and verbal orders are two areas to
explore.
It is important to note that if it is foreseeable that you may
need to perform activities outside of your scope in the
absence of a physician during emergency situations, this is
not considered to be direct supervision. Therefore you and
the employing agency must develop written policies and procedures to define expected roles and responsibilities
including educational and practical training requirments
(Advanced Nursing and Medical Nursing Shared Skills, 1993).
The third situation occurs when direct supervision is misinterpreted as a clause granting authority for nurses to
routinely perform non-urgent activities that they are not
educated or authorized to perform. The direct supervision
clause while valuable is not meant to grant blanket authority
for you to perform any medical act. The nurses performs
the activity as a matter of convenience. This is not acceptable practice (Standards for Nursing Practice, 1995).
Furthermore, if performing the act violates agency policy or
scope of practice boundaries there may be employee or liability implications where the defense " he/she told me to do
it " is of limited value. If the need to perform an activity is a
common occurrence then the formal process of delegation
of function and/or policy support with consequent training
(theory and practice) must be followed. Information on this
process is available in ARNNLs Advanced Nursing and
Medical Nursing Shared Skills Document (1993).
When interpreting direct supervision you should also consider the proximity of the supervisor. If the activity is
performed under direct supervision the supervisor must at
all times be able to observe your actions. When the supervisor is not expected to be immediately present but has
been consulted and/or is available upon request this is called
indirect supervision or consultation. This level of supervision is only designed for activities that are within the scope
of nursing practice.
Don't fall in the trap. Be sure that you are educated and
authorized to perform the nursing care services you are
providing. If you are in a situation where you or your colleagues are either willingly or unwillingly (afraid to refuse or
buck the system) routinely performing medical acts under
the perceived auspices of "direct supervision" you need to
carefully consider your situation. Talk to you manager,
review ARNNL Protocol for concerns about quality care,
call the Canadian Nurses Protective Society for advice
(1-800-267-3390), discuss the issue with an ARNNL
Workplace Representative, or give me a call.
September 2002