Nursing Law

The State Schools

  • The discussion about state schools has gained traction due to the existing nursing shortage.
  • More restrictions are being placed on Licensed Practical Nurses (LPNs), who typically have a vocational associate's degree.
  • Some hospitals still employ LPNs, but they are often grandfathered in.
  • New LPN graduates may find it difficult to secure hospital positions.
  • Bachelor of Science in Nursing (BSN) graduates are ahead of the curve.

Educational Requirements and Licensing

  • Statutory law dictates educational requirements for nurses.
  • It also governs the process of obtaining a nursing license.
  • Earning a BSN does not automatically grant a nursing license; graduates must pass a standardized test (NCLEX).
  • Statutory law defines the test's content, administration, location, and authorized personnel.

Criminal Law

  • Criminal law protects society and is defined by municipalities, states, and federal legislation.
  • Criminal offenses can be classified as misdemeanors or felonies.
  • Example: Administering an injection to someone who has refused it could be considered a felony, specifically mistreatment of a vulnerable population.

Examples of Mistreatment of Vulnerable Populations

  • Elderly people:
    • Elder neglect, such as adult children leaving elderly parents in soiled diapers for extended periods.
    • Nursing homes prioritizing profit over patient care, leading to understaffing and neglect (e.g., increasing resident-to-CNA ratios to 25:1 or 30:1).
    • CNAs primarily focusing on washing bodies without proper patient turning.
  • While some excellent nursing facilities exist, indicators of poor care include patients with bedsores or skin dried with stool.
  • Slander: Making false and damaging statements about a facility.

Administrative Law (Regulatory Law)

  • Administrative law defines expectations and duties of care.
  • Nurse Practice Act: A form of civil law that defines the duty to care for patients.

Abandonment

  • Patient abandonment occurs when a nurse leaves their shift without properly transferring care to another qualified nurse.
  • Example: A nurse with five or six patients cannot simply leave after reporting off on only some of them, even if relief is present for those patients.
  • Failure to report off on all patients constitutes abandonment, even if someone is available to watch them.

ADPIE

  • Administrative law defines the components of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
  • Evidence-based practice often structures ADPIE.
  • A nurse who fails to report unethical or incompetent behavior violates administrative law.
  • Example: Ignoring a colleague's break in sterile technique during Foley catheter insertion makes you as liable as them if the patient develops a urinary tract infection (UTI).

Policies and Procedures

  • Policies and procedures are based on Nurse Practice Act guidelines.
  • Institutions can make these policies stricter but cannot undermine the Practice Act.
  • Federal laws have to trickle down to state and local level.
  • If state legislation makes a change, the local must comply with state changes.

Example

  • Bedside report: Including the patient in their care plan.
  • Failure to do so can lead to litigation if something that could have been caught during bedside report occurs because the patient was not involved.
  • Benefits of bedside report: Identifying programming errors in feeding pumps or other equipment.

Lawsuits

  • Harm to patients leads to lawsuits, especially at the state level.
  • Statutory law (state law) makes nurses accountable.
  • State boards of nursing must notify nurses under investigation, which does not necessarily mean loss of license but carries that possibility.
  • Managers may place nurses on administrative leave during investigations.
  • Lawsuits can target the doctor, hospital, and the nurse individually.

Malpractice Insurance

  • Malpractice insurance is available for nurses but can be expensive.
  • Hospitals may not defend nurses in lawsuits, hoping liability falls on them instead.
  • Many nurses carry malpractice insurance as an individual decision.

Disciplinary Proceedings

  • The Wisconsin state legislature oversees disciplinary proceedings.
  • The Department of Safety and Professional Services (DSPS) grants licenses in Wisconsin.
  • The DSPS website allows verification of licenses (nursing, electricians, etc.) and their status.
  • Complaints against nurses are filed with the state board of nursing.

Fraud

  • Fraud: Intentional perversion of the truth to induce another to part with something of value or surrender a legal right.

Incompetence

  • Incompetence: Not giving enough care or attention.
  • Abuse of alcohol and drugs.
  • Mental incompetency: Practicing with diagnosed mental deficits.
  • Working while intoxicated, even with prescription drugs.

Unprofessional Conduct

  • Unprofessional conduct related to code status and power of attorney (POA).
  • Manipulating patients regarding DNR orders.
  • Trying to banter patients into changing their mind.
  • If license suspended, can apply again after ONE year, but the suspension remains on the permanent record.

Reducing Risk

  • Risk management departments exist in every hospital.
  • They provide guidance on handling difficult family members or situations.
  • Patients/families are not legally allowed to take pictures of monitors or equipment to build a case.
  • If a patient photographs the monitor or some other piece of equipment, they can be removed from the building.

Quality Improvement

  • Quality improvement involves continuous efforts to improve patient safety and outcomes.
  • APA style is relevant in quality improvement committees.
  • It's very important to never be afraid to raise a safety concern.

Examples of Potential Risk.

  • When Advocate and Aurora merged, some policies went south, some came north; they were picking what they wanted to do.
  • Neurosurgeon fired for refusing to comply with new policy.
  • Evidence-based practice is important.

LUCAS Device

  • Lucas device: Automated CPR device.
  • Evidence-based practice supports its use, even though some nurses find it boring.
  • Positive outcomes for the patient outweigh personal preference.

Ascension St. Joe's

When arriving at the parking garage at St. Joe's, there is only one entrance that can be used, located on the second floor. One must enter the hospital using the skybridge. If there isn't anyone to let you in, use the intercom to ask security to let you in.

Protecting Yourself

  • Avoid posting patient information on social media (HIPAA violation).
  • Taking pictures for charting purposes is acceptable with secure hospital cameras and servers.
  • Clarify unclear orders, especially if outside normal practice.

Reducing Risk (Chemical Dependency)

  • PAC: Professional assistance program or procedure under supervision of a state board that facilitates rehab for nurses who are chemically dependent and have not caused patient harm voluntarily.
  • Drug diversion = Illegal.
  • Don't shoot up in the broom closet - true story.
  • We all came into nursing for different reasons! Hold on to that.
  • Nurses who are chemically dependent on drugs or alcohol who has not caused patient harm. can self identify.
  • This will facilitate rehab
  • Not disciplinary.
  • Voluntary and confidential.
  • The PCA program is confidential but can create a safety net in case of a bomb being dropped like, Yes. I am. I have not hurt anyone, and I have evidence that I'm trying to fix this.
  • There is another option besides PAC, which is a departmental referral, but the nurse must be weary of how you approach someone because you can lose a friend.
  • Protect yourself with regulations

Interprofessional Collaboration and Systems Thinking

  • Interprofessional collaboration, systems thinking, and delegation are important.

Effective Collaboration

  • Efficient, patient oriented, goal oriented, cohesive.
  • Understanding what different departments do that can support the team effort.
  • Good communication.

Desired Outcomes of Effective Collaboration

  • Patient satisfaction slash survival. Better patient outcomes.
  • Improved interprofessional collaboration.
  • Morale boost.
  • Better unit dynamics, a half year working environment.

Negative Outcomes/Ineffective Collaboration

  • Failure to rescue (failure to recognize a change in their patient condition, failure to respond to condition changes even if you see it).
  • The secondary victim is the nurse who is left with guilt, shame, or becomes frozen to inaction.
  • First year nursing burnout because the toxic environment.
  • In clinical, you probably see staff nurses playing a game on their phone, shopping for a wedding dress, planning their next vacation, grading CTAs, etc. = Veteran’s decision!
  • Your first year of nursing, if you're sitting at the nurses' station with your feet up reading a novel, you're not gonna be looked on favorably by the veterans because YOU DON'T KNOW WHAT you're doing!

Strategies to Enhance Collaboration.

  • Mutual respect and trust.
  • Listen with intention.
  • Read back to verify you understand what that is.
  • Be curious.
  • Be opened what others have to say.
  • A good ohysician runs code by stpping and asking for ideas.
  • Know yourself. Know your own abilities. How are you feeling?
  • Embrace the value of diversity, which is very much respectful.
  • Anytime something bad happens, you have to fill out an event report (not punitive).
  • Nurses & team members should NOT hesitate to report deviation from standards of care.
  • Communicate often!

Strategies to Enhance Performance

  • Commit to common goal: Start with the unifying purpose, believe in what you're doing why you're doing it, and really helps establish that report with your patient.
  • Believe in those around you even if they're incompetent since that is a separate conversation from whether someone is dumb but is practicing incompetence.
  • Stay with the process and relationship- not just the solution! Follow the policies
  • Develop structure conflict resolution skills- conflict can make better decisions.

Barriers to Effective Collaboration

  • Lack of communication is the biggest barrier.
  • Poor communication skills.
  • Information hoarding: Purposely omitting critical information.
  • Mismatch of knowledge and role goals.
  • Culture of a work environment.
  • Failure to value a teammate who didn't get hired to show of wealth skills. They have something to offer because maybe they have skills you don't know.

The Interprofessional Health Care Team

  • For each patient are lots of different specialists that may be a part of their care.

QSEN

  • QSEN (Quality and Safety Education for Nurses) defines quality, safety, and education in nursing.
  • IPEC (Interprofessional Education Collaborative): Opportunities to get to talk to other professionals and see how they are thinking. They throw you in teams and given you a scenario to figure out.
  • TeamSTEPPS: Systemic communication approach to interprofessional collaboration.

TeamSTEPPS strategies

SBAR
  • Situation
  • Background
  • Assessment
  • Recommendation (nurses often forget to do). When you give a Recommendation (and are right), you must know something!
  • If you get shot down from the Physician, it does not mean you are wrong. They might know the patient a little better and may want to go in a different direction. A good physician will explain those recommendations (esp. when waking at 0030)
CUSS

  • I have a Concern

  • I am Uncomfortable

  • Safety Concern

  • On a good unit, everything will stop. Does not matter how green (new) you are, it is a hard stop!

  • The are chain of commands to go through.

Check Back
  • Restate what the person said to verify understanding. ie
Call Out
  • Shout out important information (not screaming)
  • In Code- Situation- Open loop communication
Closed Loop
  • Give one amp of epinephrine (as the team lead directs)
  • Registered: Give one amp of epinephrine
  • Student: One emp of epinephrine
  • Registered: Okay; Administers drug and, epinephrine given since someone is documentint the entire code with time stamps

Two Challenge Rule:

  • State concern twice, Escalate chain of command if ignored. Have gone through it before!

Rights of Delegation:

  1. Right task
  2. Right circumstance
  3. Right person
  4. Right communication
  5. Right supervision

Systems Thinking

  • You gotta to create a big picture!
  • The whole unit!