I know our list mothers have called a moratorium on posting about the SOP
but as one of the 3000 silent lactnetters I feel a need to weigh in this once.
First of all I'm not sure how a credentialing body can even delineate a
scope of practice. At one time I was an RNC which means that I was certified in
my area of specialty -- high risk neonatal. I studied like mad and then took a
pretty difficult exam. This is what I was certified to do--absolutely
nothing beyond what I was licensed to do as an RN. What it did provide is evidence
to my current or subsequent employer that I took the time and spent the
money to prove that I was a competent test taker. Hopefully it also conveyed that
I had a fairly complete body of knowledge in high risk neonatal nursing. It
did not enlarge my scope of practice in any way, however.
I never thought about my international board certification in lactation in
the same way, but indeed is it any different? Can anyone think of any other
credentialing body which delineates a scope of practice for its credentialees?
When we look at the scopes of practice for PT's, psychologists, etc. these
come from licensing boards not credentialing organizations. Even a
physicians who is not board certified in a particular specialty can still, for the
most part, practice in that specialty. Is it not the physician's licence which
outlines the scope of practice? (I would love to have any physicians on
Lactnet let me know if I am on track about this.)
As far as our current SOP it is neither realistic nor possible to practice
without recommending alternative therapies, not that the board has even
attempted to define what it means by "alternative".
As far as diagnosing it is very possible for us to do our job without
diagnosing--nurses have been doing this for years. As in, "you have all the signs
and symptoms of mastitiis. You need to call your HCP right away. It is
important for you to continue to breastfeed your baby. The milk is perfectly safe.
If the pain is too great on the affected side for your baby to nurse you will
need to pump since milk stasis will make the infection worse and will reduce
your milk supply. I would also advise you to try to get someone to help you
so you can be on bedrest. Most mothers begin to feel better within 24-48 hr.
of starting antibiotics, but it is important for you to take all of the
antibiotics prescribed so no resistant bacteria will be left. If your HCP has any
questions please have him/her give me a call. If you are not feeling better
within 48 hr. or you get worse please give your HCP a call."
Now by stating "you have all the signs and sx of mastitis" I have not
diagnosed, just described what I am seeing or hearing." It's a matter of semantics.
And as far as treating a medical condition, as someone said I don't have one
of those little pads with my name and medical license on it, so I definitely
cannot prescribe a medication. And I would never presume to treat a medical
condition because this would be construed as practicing medicine without a
license and would jeopardize my nursing license.
The final tenet of the SOP states that "contradicting or ignoring the advice
of a client's health care provider" is outside of the SOP of an IBCLC. I'm
pretty sure that most of us in little ways get around this almost every day
we work. I'm very careful, however, not to put my nursing license in jeopardy.
There are times that I cannot contradict a physician's advice even though it
kills me to have to go along with it. If it endangered the life or safety of
a pt. I would and could refuse to carry out an order. But it is seldom that
clear cut. When an HCP tells a new mother she has no milk, I gently but
thoroughly explain that she has sufficient newborn milk for her baby, called
colostrum, and that frequent breastfeeding without supplementation will insure
that her breasts make the amount of milk the baby needs. When an HCP orders
formula after every breastfeeding, without assessing the infant's ability to
breastfeed effectively, because the infant's bilirubin is in a high risk zone
it's a little bit more of a slippery slope. As the dyad leaves the hospital
I cannot advise them to ignore this advice. If that baby goes home and does
not bf well, loses more wt. and jaundice increases my license is on the line
for advising them to ignore their doctor's advice. What I can do is advise the
mother to rent a hospital grade pump, to pump after every breastfeeding so
she can protect her supply and to arrange for lactation follow up so she can
get her baby back to full breastfeeding as soon as possible.
Finally, I'd like to share an example of a pretty dramatic instance when I
had to contradict a physician's advice. I was working in an outpt. lactation
clinic. A mother who had been exclusively breastfeeding for 5 or 6 months was
referred to me by her OB office. She had recently been treated for mastitis
and had returned to the OB because her breast did not look at all normal. He
told her it was a plugged duct and the lactation consultant could help her.
The entire outer aspect of her left breast was red, swollen and looked to me
almost like a cellulitis. It was painful to the touch but she had no fever or
systemic sx of mastitis. I told her it did not look like any plugged duct I
had ever seen and that I was going to call her OB to discuss what I was
observing (fearing that it was cellulitis or an abscess). I spoke to the OB's
nurse who told me that the OB did not want to speak to me. He told the RN that
he had diagnosed a plugged duct and that was what it was. He also refused to
see or speak to the patient again. I now had a dilemma. I knew this was not a
plugged duct but something more serious. Luckily, there was a breast surgeon
who worked in the same complex of offices as ours and she also had recently
breastfed her own baby. We had referred pts to her in the past. I asked the
mother, who luckily had a PPO so she could self refer, if she would see the
surgeon and she readily agreed. I then called the surgeon who was able to fit
the pt. in and drained a 1/4 of a cup of pus from an abscess. The surgeon
called me back to let me know that within a day this mother would have been very
sick and would have required hospitalization. The surgeon subsequently sent a
letter to me and the OB thanking me for the referral and the OB for the
privilege of treating his pt. describing the situation she encountered and her
tx. I hope he got the point. So in this instance the mom's well-being
dictated I contradict the physicians findings. If the mother had not been well
insured and had not been able to self refer I guess I would have had to send her
to the ER.
So-- I'm not sure having a SOP for a credential helps us. I do think this
whole issue points to the need for a specified educational tract culminating in
licensure for our profession. In the mean time I hope the board removes
ambiguities from the SOP because at this time we have little choice if we are to
provide good care except to ignore them.
Kathy Boggs, RN, IBCLC
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