Health care law and legislation

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Nursing and the Law

Chapter 9

LEARNING OBJECTIVES

Describe why and how the role of nurses continues to evolve and expand.

Explain the process of obtaining nurse licensure.

Discuss the various categories of nursing staff.

Describe a variety of the legal risks nurses encounter in the practice of nursing.

Scope of Practice

Permissible boundaries of practice for health care professionals, defined in state statutes, which define the actions, duties, & limits of nurses in their particular roles.

Role of nurse continues to expand due to

shortage of primary care physicians

ever-increasing specialization

improved technology

public demand

expectations within the profession itself.

NURSING DIAGNOSIS

Various states recognize that nurses can render a nursing diagnosis.

e.g., Section 335.01(8) of the Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis.

Nurse Licensure

Requirements for Licensure

Reciprocity

agreement between states whereby a nurse licensing board in one state recognizes licensees of another state.

Endorsement

boards determine if out-of-state nurses' qualifications are equivalent to their own state requirements at the time of initial licensure.

Nurse Licensure - II

Waiver

When applicants do not meet all the requirements for licensure but have equivalent qualifications, the specific prerequisites of education, experience, or examination may be waived.

Examination

Some states will not recognize out-of state licensed nurses & make it mandatory that all applicants pass a licensing examination.

Suspension & Revocation

Violations may include

procurement of a license by fraud

unprofessional, dishonorable, immoral, or illegal conduct

performance of specific actions prohibited by statute

malpractice.

Practicing without a License

Health care orgs are required to verify each nurse's license is current.

Mere fact that an unlicensed practitioner is hired will not generally in & of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurse's negligence.

Classification of Nurse Staff

Nurse Managers

Chief nursing officer has responsibility for:

maintaining standards of practice

maintaining current p & ps

recommending staffing levels

coordinating & integrating nursing services with other patient care services

selecting nursing staff

developing orientation and training programs.

Nurse Managers – II

Failure to supervise

can lead to disciplinary action

Registered Nurse

Graduation from accredited nursing program

Pass national licensing exam

National Council Licensure Examination

LPNs & LVN

Graduation from accredited nursing program

Pass a licensing exam approved by the state

Routine nursing care

vital signs, injections, assist patients, etc.

under direction of an RN or physician

Float Nurse

Nurse who rotates from unit to unit based on staffing needs.

Can benefit understaffed unit but also may present a liability as well if they are assigned to work in an area outside their scope of expertise.

If a patient is injured due to floater's negligence, standard of care required will be that required of a nurse on the assigned patient care unit.

Agency Nurse

Risk for negligent conduct of agency staff.

Agency workers must have necessary skills & competencies to carry out duties & responsibilities assigned.

Case: Resuscitation of Choking Child Fails

Special-Duty Nurse

A health care professional employed by a patient or patient's family to perform nursing care for the patient.

If a master-servant relationship exists between the org & special-duty nurse, doctrine of respondeat superior may be applied to impose liability on the org for nurse's negligent acts.

Traveling Nurse

Nurse who travels to work in temporary nursing positions in different cities and states.

independent contractors or

elect to work with one or more recruitment agencies

Opportunities that include higher wages.

Skills enhanced with exposure to intriguing assignments.

Student Nurse

Student nurses are entrusted with the responsibility of providing nursing care to patients.

Students are personally liable for their own negligent acts, & the facility is liable for their acts on basis of respondent superior.

Student nurse are held to the standard of a competent professional nurse when performing nursing duties

Advanced Practice

Nurses

The Role of Nurses Extends Beyond the Hospital Ward

A nurse is a doctor’s best friend, according to Marvin M. Lipman, Consumers Union’s chief medical adviser. This advice was given to him by a hospital ward’s head nurse when he was a third-year medical student making contact with patients for the first time, along with the suggestion that he’d do well not to forget it.

–Consumers Union of United States Inc., The Washington Post, May 30, 2011

Nurse Practitioners

RNs who have completed education to engage in primary health care decision making.

Trained in delivery of primary health care & assessment of psychosocial & physical health problems such as the performance of routine examinations & ordering of routine diagnostic tests.

NP Negligence

Responsible for negligent acts

Can imputed to physician

The Role of Nurses Extends Beyond the Hospital Ward

Nurse practitioners . . . Studies have found that their ability to diagnose illnesses, order and interpret tests, and treat patients is equivalent to that of primary-care physicians. They also tend to spend more time with patients during routine office visits than physicians, and they are more likely to discuss preventative health measures. As of 2010, 140,000 NPs were working in the United States.

–Consumers Union of United States Inc., The Washington Post, May 30, 2011

Clinical Nurse Specialist

Clinical nurse specialist is a professional RN with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics, psychiatry).

CNS acts as a resource for the management of patients with complex needs and conditions.

The CNS participates in staff development activities related to his or her clinical specialty & makes recommendations to establish standards of care for those patients.

Clinical Nurse Specialist – II

CNS functions as a change agent by influencing attitudes, modifying behavior, & introducing new approaches to nursing practice.

CNS collaborates with other members of the health care team in developing and implementing the therapeutic plan of care for patients.ard of care

Certified Nurse Anesthetist

Education and Certification

Oversight of an anesthesiologist often required

Major risks include

improper placement of an airway

failure to recognize significant changes in a patient's condition

improper use of anesthetics

Certified Nurse Midwife

Provide

delivery for patients at low risk for complications

often manage normal prenatal, intrapartum, & postpartum care.

Certified Nurse Assistant

Aide who has been certified & trained to assist patients with activities of daily living under the direction & supervision of an RN or LPN.

Help with positioning, turning, lifting & performing a variety of tests * treatments.

Case: Failure to follow policy & safe practices

Legal Risks of Nurses

NURSING LEGAL RISKS

Patient Assessments

Failure to Conduct a Proper Examination

Failure to Take Vital Sign

Failure to take vital signs.

Failure to Monitor Vital Signs

Delay in Monitoring Fetus

Untimely Reassessment

Failure to Repeat Vital Signs

NURSING LEGAL RISKS - II

Treatment

Delay in Treatment

Failure to Follow Physician’s Orders

Burns from Bovie Machine

Failure to Note Patient’s Airway Became Dislodged

Treating Wrong Patient

NURSING LEGAL RISKS - III

Infections

Failure to follow proper infection-control procedures

proper hand-washing techniques

Cross contamination of patients

NURSING LEGAL RISKS - IV

Negligent Care Causes Laceration

Negligent Amputation of Infant’s Finger

Failure to Follow Instructions

Delay in Reporting Patient’s Condition

NURSING LEGAL RISKS - V

Failure to Note Change in Patient’s Condition

Failure to Verify Orders

Failure to Report Deteriorating Condition

Delay in Reporting a Patient’s Condition

NURSING LEGAL RISKS - VI

Discharge

Failure to Act: Swollen Beyond Recognition

Discharge: Infants Switched

CASE: Nursing Diagnosis Court’s Decision

Defendant physicians ignored nurse's assessment of patient's diagnosis, which contributed to delay in treatment & injury to the patient. Nurse testified that she told the physician that patient's signs & symptoms were not those associated with indigestion. Defendant physician objected to this testimony, indicating that such a statement constituted a medical diagnosis by a nurse. The trial court permitted the testimony to be entered into evidence.

What do you think happened on appeal?

CASE: Nursing Diagnosis

Missouri Court of Appeals affirmed lower court's ruling, holding that evidence of negligence presented by a hospital employee, for which an obstetrician was not responsible, was admissible to show events that occurred during patient's hospital stay.

See text case: Cignetti v. Camel

Medications Errors

Failure to Identify Correct Patient

Failure to administer Medications

Administering the Wrong Medication

Administering the Wrong Dosage

Failure to Clarify Orders

Medications Errors - III

Administering wrong dosage

Administering Drugs by the Wrong Route

Failure to discontinue a drug

Failure to note a change order

Infections

Cross Contamination

Failure to Notify Physician

Failure to follow established procedures

Infection control

Sterile technique

CASE STUDIES

Negligent Care Causes Laceration

Failure to Follow Instructions

Failure to Question Discharge

Chance of Survival Diminished

Case 1a: Negligent Care Causes Laceration

Plastic cup as arm guard?

Morris alleged from personal observation that the laceration to her daughter's arm was caused by the jagged edges of a plastic cup that had been split & placed on her arm to guard an IV site.

Text case: Morris v. Children’s Hospital Medical Ctr.

Was this a breach of the standard of care for nurses?

CASE 1b: Negligent Care Causes Laceration

A nurse, in her affidavit, who stated her qualifications as an expert, expressed her opinion that the practice of placing a split plastic cup over an IV site as a guard constituted a breach of the standard of nursing care.

CASE 2a: Failure to Follow Instructions

Failure of a nurse to follow the instructions of a supervising nurse to wait for her assistance before performing a procedure can result in revocation of the nurse's license.

Heart monitor was connected incorrectly & resulted in an electrical shock to the infant.

Dangers of electric cords are within the realm of common knowledge.

Record showed the nurse failed to exercise ordinary care in connecting the infant.

Text Case: Cafiero v. North Carolina Board of Nursing

CASE 3a: Failure to Question Discharge

Premature Discharge

A nurse has a duty to question the discharge of a patient if he or she has reason to believe that such discharge could be injurious to the health of the patient.

See text case: Koeniguer v. Eckrich

CASE: 3b Failure to Question Discharge

The hospital's negligence is based on acts of omission, by failing to have the patient examined by a physician and by discharging her in pain.

The evidence presented a woman conscious of her last days on earth, swollen beyond recognition, tubes exiting almost every orifice of her body, in severe pain, and who deteriorated to the point where she could not verbally communicate with loved ones.

See text case: NKC Hosps., Inc. v. Anthony

CASE 4a: Chance of Survival Diminished Ard v. East Jefferson Gen. Hosp.

Husband was having difficulty breathing

Rang the call bell for 1.25 hours before anyone responded

Code eventually called

Patient did not survive

CASE 4b: Chance of Survival Diminished

Physicians’ progress notes patient high risk for aspiration

Problem never addressed

nurses’ care plan or in the nurses’ notes

Trial judge’s conclusion:

the nursing staff breached standard of care

patient would have had a much better chance of survival if he had been transferred to the intensive care unit

REVIEW QUESTIONS – I

1. Describe how the scope of nursing is changing.

2. Describe how the roles of a nurse anesthetist, clinical nurse specialist, nurse practitioner, and nurse midwife differ.

3. Describe the various medication errors that can occur in the administration of medications.

REVIEW QUESTIONS – II

4. If a nurse disagrees with a physician's written orders, discuss what action the nurse should take to protect the patient’s safety.

5. Discuss why it is important to report significant changes in a patient’s condition to the treating physician.