Chapter 39 vol 1 week 3
Nurse Practice Acts (NPAs) and Scope of Practice
NPAs vary slightly by state, but generally, the licensed practical nurse (LPN) scope of practice has limited assessment privileges and interpretation of clinical data.
Typically, LPNs or licensed vocational nurses (LVNs) do not have the authority to alter nursing care plans.
It is crucial to know the requirements of your particular state as they determine the legal limits of your nursing practice.
Landmark Case: Scope of Practice
Case Example: Barber v. Reinking (1966)
A physician delegated the task of administering a polio booster to a 2-year-old boy to an LPN.
The LPN put the boy over her knee to administer the injection; the boy moved, causing the needle to break off and remain in his buttocks for 9 months.
The Washington State Nurse Practice Act at that time prohibited LPNs from giving injections.
The LPN violated the NPA by performing a task beyond her legal authority.
Disciplinary Actions for Violating NPAs
The state board of nursing has the authority to take disciplinary actions against your nursing license for NPA violations.
Process of Disciplinary Action:
Begins with a complaint from an individual, employer, or professional organization regarding unprofessional conduct.
Assigned to an investigator to determine validity.
If invalid, it is dismissed.
If potentially valid, further investigations, such as witness interviews and document reviews, are conducted.
The case may be presented before the board of nursing for a decision on whether the NPA was violated and the subsequent punishment.
Due Process Requirements (Fourteenth Amendment):
Notice of charges against you (typically a letter via certified mail).
Evidence supporting the charges.
Opportunity for a hearing to cross-examine witnesses and present personal evidence.
Appeal Process: If unsatisfied with the board's actions, the case can be appealed to the appropriate state court.
Right to Legal Representation: At any stage of the disciplinary process, you have the right to an attorney.
Questions to Ask a Potential Attorney:
How many of your cases involve administrative law and procedures?
How many times have you represented clients before a professional board, such as the nursing board?
Unprofessional Conduct in Nursing
Nurses displaying actions potentially harmful to patients or coworkers may exemplify unprofessional conduct.
Examples of actions categorized as unprofessional or derogatory to nursing standards:
Acting outside of your legal scope of practice.
Inaccurately recording, altering, or destroying patient records or directing others to do so.
Failing to document nursing interventions timely and accurately.
Failing to communicate patient status information promptly to necessary personnel.
Inflicting intentional or careless harm to a patient, which includes misuse of medications or restraints, verbal/sexual abuse, or exploitation.
Violating patient confidentiality or misappropriating patient property.
Neglecting to safeguard patients from incompetent practices of others.
Accepting duties which you are not trained or competent to perform.
Impersonating another licensed individual.
Diverting medications or supplies for personal use.
Engaging in threatening or abusive behavior towards a coworker.
Reference: Kansas State Board of Nursing (1993, last amended 2016); Oregon Board of Nursing (2017).
Case Study: Clinical Judgment in Action
An RN assigned to a 76-year-old stroke patient faced allegations of misconduct despite providing care professionally.
The case underlines the importance of documentation and communication among patients and families to guard against unprofessional conduct allegations.
Patient Protection Laws and Credentialing
Patient Care Partnership, Code of Ethics for Nurses, Mandatory Reporting Laws:
These frameworks protect patients and establish ethical boundaries for nursing practice.
Credentialing: A voluntary self-regulation process crucial to maintaining high standards in nursing.
Includes certification and accreditation processes to indicate that individuals or institutions meet established standards beyond minimum qualifications.
Accreditation:
Nursing programs must be accredited by recognized agencies to ensure education meets quality standards for patient care (e.g., ACEN, CCNE, CNEA).
The Joint Commission also accredits healthcare facilities meeting established care quality standards.
Legal Aspects of Nursing
Criminal Law
Deals with society's offenses and can result in state or federal prosecution.
Crimes are classified as felonies (punishable by over 1 year in prison) or misdemeanors (less than 1 year).
Examples of Felony Crimes: murder, assisted suicide, theft of controlled substances.
Consequences of Felony Conviction: loss of voting rights, public office eligibility, jury service, firearms possession, and potential loss of professional license.
Examples of Misdemeanor Crimes: assault, petty theft, which also can lead to disciplinary actions against nursing licenses.
Defendant Rights: Includes the right to an attorney and the right to remain silent.
Cases in Criminal Law:
A nurse accused of stealing pain medication and providing saline instead faced felony theft charges.
Another scenario involved a nurse charged with grand larceny for stealing medical supplies valued at $55,000, which was reduced to a misdemeanor with probation and reimbursement of the stolen amount.
Are Nursing Errors Crimes?
Increasing trend for state prosecutors to charge nurses criminally for accidental patient harm.
Example: A nurse was charged with involuntary manslaughter for a patient’s death due to negligence in assessing injury after a fall.
Documentation Responsibilities
Fundamental documentation guidelines must ensure that a third party can read records and understand the care provided.
Key Points to Document:
All patient interactions and treatment refusals.
Communications with healthcare providers, including details about timing and content.
Factual, objective information with no personal opinions.
Accurate records of important details, timely entries, and unusual occurrences.
Assessment data and nursing plans/responses.
Guidelines for Documentation: Use the acronym F-A-C-T-U-A-L
F: Factual & Objective
A: Accurate
C: Complete
T: Timely
U: Unusual occurrences
A: Assessment data documented
L: Legal considerations of medical records.
Informed Consent in Nursing
Informed Consent: Patient approval for treatments after being informed of risks, benefits, alternatives, and costs.
Written consent is required for hospital admissions and invasive procedures unless it’s an emergency.
Elements of a Valid Informed Consent:
Completeness: Adequate information for decisions.
Clarity: Understandable language for the patient.
Voluntariness: Patient freedom from coercion.
Competence: Patient's capacity to understand and decide about treatment options.
Nurse’s Role: Nurses collaborate with primary providers to ensure consent validity, though they should not solely explain procedures.
Obtaining informal consent for nursing interventions is crucial.
Case Example: Breakdown in Informed Consent
A pulmonologist's failure to have a clear informed consent process led to a patient experiencing severe complications from an untreated condition.
This lack of informed consent was grounds for a lawsuit (Gonsalves v. Sharp, 2013).
Patient Safety
Falls are common incidents requiring constant assessment and preventive measures upon patient admission to healthcare facilities.
Fall Precautions:
Not merely raising bed railings; nurses must ensure effective communication and patient accessibility to assistance.
Patient Responsibility: Ensure the call device is within reach to report needs for help.
Maintenance of Confidentiality and Privacy
Confidentiality: Protecting patient information unless legally required to disclose.
Rights of Family Members: Family does not have an automatic right to access the records of the patient.
Discussions about the patient's health must be confined to necessary medical personnel only.
Education and Counseling Responsibilities
Nurses must effectively educate patients about their health conditions, treatments, and medications to fulfill informed consent and active participation in care duties.
Strategies for proper patient education include active engagement, comprehension checks, and providing opportunities to demonstrate understanding.
Delegation Practices
Proper delegation is crucial for patient care involving five rights:
Right person, right circumstance, right direction, right supervision, and right evaluation.
Delegation criteria must consider the individual qualifications of the delegatee and the patient's needs.
Common faults include assuming LPNs or unlicensed personnel can provide complex care independently without adequate supervision and assessment.
Conclusion
Clear understanding, adherence to lawful practices, and effective communication are essential for maintaining nursing standards and ensuring patient safety and quality care adjustments.