Legal Responsibilities in Nursing

Legal Responsibilities in Nursing

• Nurses mitigate liability risks and protect client rights by understanding nursing practice laws
• Nurses are responsible to practice within legal boundaries, advocate for client rights, provide care within their scope of practice, understand their role within the health team, and deliver safe care consistent with standards

Sources of Law

• Federal regulations are made of federal laws applicable to nursing
• HIPAA: Health Insurance Portability and Accountability Act is such an example
• ADA: Americans with Disabilities Act, is another federal law
• MHPA: Mental Health Parity Act, is also an example of a federal law
• PSDA: Patient Self-Determination Act, one more example of federal law affecting practice

Criminal and Civil Laws

• Criminal Law: A subsection of public law that focuses on the relationship between individuals and the government
  • An example is if a nurse falsifies a record to cover up a serious mistake, they can be charged with a crime
• Civil Law: Protects individual rights
  • Tort law, applicable to nursing care, is a type of Civil Law

State Laws

• Each state has statutes defining nursing practice parameters and delegates the regulation of nursing practice to its state board
• State boards of nursing can adopt rules further regulating nursing practice
• Nurses must know nursing laws and rules in the state where they practice, though practice may be similar among states
• These boards can issue and revoke nursing licenses
• Nursing program standards are set by boards, including the scope of practice for RNs, PNs, and advanced practice nurses
• Good Samaritan laws exist in all states, protecting health care workers from liability when assisting at emergencies

Licensure

• Nurses should have a current license in every state where they practice
• States that have adopted the Nurse Licensure Compact are exceptions, about half of them
• This compact allows nurses in a compact state to practice in other compact states under a multistate license
• Nurses in the compact must practice following the statues and rules of the state where they provide care

Types of Torts

• Unintentional Torts:
  • Negligence: A nurse does not implement safety measures for a client at risk for falls
  • Malpractice: Nurse gives a large dose of medication due to a calculation error, and the client has cardiac arrest
• Quasi-intentional torts:
  • Breach of Confidentiality: A nurse shares a client's medical diagnosis with the press
  • Defamation of Character: A nurse tells a coworker they believe the client is unfaithful
• Intentional Torts:
  • Assault: When a nurse threatens to place an NG tube in a client refusing to eat, it makes the client fearful
  • Battery: A nurse restrains a client and administers an injection against their wishes
  • False Imprisonment: A nurse uses restraints on a competent client to prevent them from leaving the health care facility

Professional Negligence

• Professional negligence occurs when a trained professional fails to act reasonably and prudently
• A "reasonable" and "prudent" person is someone with average judgment, intelligence, foresight, and skill
• Negligence issues often leading to malpractice suits: Failure to follow standards of care, use equipment responsibly, communicate well, document care, notify changes, and complete procedures
• Nursing students can be liable for harm from direct actions or inaction; they should not perform unprepared tasks and need supervision
  • Students, instructors, schools, and facilities may share liability for wrong actions or inaction
• Nurses can avoid liability for negligence by:
  • Following standards, giving competent care, communicating, building rapport, documenting assessments, being familiar with facility policies etc

Five elements necessary to prove negligence

• Duty to Provide Care: A nurse should complete a fall risk assessment for all clients during admission.
• Breach of Duty: Standard of care wasn't met, so the nurse doesn't perform a fall risk assessment during admission
• Foreseeability of Harm: The failure to take fall risk precautions could endanger a client at risk for falls.
• Potential to Cause Harm: The nurse is not aware of the client's risk of falls without a fall risk assessment, so they do not take proper precautions.
• Harm Occurs: The client falls out of bed and fractures their hip

Clients' Rights

• Nurses are accountable for protecting client rights, including informed consent, refusal of treatment, advance directives, confidentiality, and information security
• Clients have legal privileges or powers when they get health care services
• Clients in health care institutions retain their rights similar to other citizens

Nursing Role in Clients' Rights

• Nurses ensure clients understand and protect their rights
• All clients have the right to understand care, be active in decisions, accept/refuse/modify care, and receive respectful care

Informed Consent

• A legal process where a client legally gives permission for a procedure or treatment
  • Consent is informed when a provider explains the reason, benefits, risks, and other options to the client
• Nurses must witness the client's signature on the form; ensuring the provider obtained consent responsibly

Informed Consent Guidelines

• Clients must consent to all care in a health care facility
• Implied consent is adequate for most nursing care; clients comply with nurse instructions to give the consent
• Written consent is needed for an invasive procedure or surgery
• State laws determine who can give informed consent, this is dependent on age and emergency situations
  • Nurses have to know the laws for the state(s) where they work

Responsibilities for Informed Consent

• Provider: Must obtain informed consent by giving the client the purpose, complete description and professionals that will participate in the procedure
• Client: Must give informed consent voluntarily if they are competent and of legal age
• Nurse: Must act a witness to the informed consent by ensuring the provider gave the client the necessary information and that the client understood the information

Requirements for Granting Consent

• A trained medical interpreter is needed if language barriers or hearing impairments exist
• Individuals who can grant consent for another: parent of a minor, legal guardian, court specified representative etc
• Emancipated minors (minors who are independent from their parents) can consent for themselves
• A mature adolescent is included in the consent process by signing an assent as a part of the informed consent document
• A competent adult must sign the informed consent as long as they are capable of understanding the necessary information

Refusal of Treatment

• According to PSDA (Patient Self-Determination Act), staff must inform clients of their right to accept or refuse care when they are admitted to a health care facility
• Competent adults can refuse treatment, including leaving a facility without a prescription from a provider
• If a client refuses treatment, the client signs a document to acknowledge their understanding of the risks involved and that they have chosen to refuse it
• If a client leaves the facility against medical advice, the nurse must notify the provider and discuss the risks with the client prior to discharge
  • The nurse will then ask the client to sign an Against Medical Advice form and documents the incident

Standard

• Nurses base practice on established standards of care or legal guidelines for care
  • Nurse practice act of each state
  • Published standards of nursing practice from professional organizations such as ANA, AACN and AAOHN
  • Health care facilities policies and procedures for employees, that have procedures about how the nurse should respond or provide care

Standards of Care

• Standards of care direct the level of care nurses should give and can implicate nurses who did not follow these standards in malpractice lawsuits
• Nurses cannot practice beyond the legal scope of practice or outside of their areas of competence
• Nurses should verbalize concerns related to assignment in light of current legal scope of practice

Impaired Coworkers

• Impaired health care providers have a significant risk to client safety, so nurses must report co-workers who show dangerous behavior that could be related to substance abuse
• Many facilities have programs to provide assistance programs that facilitate entry into a treatment programs
• Each state has laws and regulations that govern the disposition of nurses with substance use disorders. Criminal charges could apply

Advance Directives

• The point of advance directives is communicate a client's wishes regarding end-of-life care, should they be unable to do so
• The PSDA requires asking all clients on admission to a health care facility whether they have advance directives.
• Staff should give clients who do not have advance directives written information with the outline needed to make health care decisions
• A health care representative should be available to help with this process

Types of Advance Directives

• Living will: Expresses the client's wishes regarding medical treatment in the event of incapacitation and end-of-life
  • Most state laws protect health care providers who follow a living will from liability
• Durable power of attorney for health care: Clients designate who will make health care decisions for them in the event they are unable to

Nursing Role in Advance Directives

• Nurses must give written information about advance directives
• Nurses also document the client's advance directives status
• The nurse must ensure the advance directives reflect the client's current decisions
• The nurse must inform all members of the health care team of the client's advance directives

Mandatory Reporting

• In line with state law, health care providers have a right to report their findings
• Abuse: Nurses need to report suspiciions of child, elder or adult violence
• Communicable Diseases: Nurses report communicable diseases to the local or state health department as is required by law
• Reporting allows officials to:
  • Ensure proper treatment of TB, monitor for common-source outbreaks like foodborne hepatitis A, plan and evaluate control/prevention plans like immunizations, determine public health priorities, and recognize outbreaks/epidemics