Nursing Chapter 23: Legal Implications in Nursing Practice

Legal Limitations of Nursing Practice

• Sources of law include constitutional law, statutory law (civil and criminal), administrative law, common law, and case law.
• Scope and standards of nursing define nursing and reflect the values of the nursing profession.
• Standards of nursing care reflect the knowledge and skill ordinarily possessed and used by nurses.

Federal Statutes Affecting Nursing Practice

• Patient Protection and Affordable Care Act (PPACA) ensures consumer rights and protections, affordable health care coverage, increased access to care, and quality of care that meets the needs of patients.
• Emergency Medical Treatment and Active Labor Act prohibits the transfer of patients from private to public hospitals without appropriate screening and stabilization.
• Health Insurance Portability and Accountability Act (HIPAA) provides rights to patients and protects employees.
• Health Information Technology Act requires nurses to protect protected health information (PHI).
• Americans with Disabilities Act (ADA) protects the rights of people with physical or mental disabilities.
• Mental Health Parity and Addiction Equity Act requires health insurance companies to provide coverage for mental health and substance use disorder (SUD) treatment.
• Patient Self-Determination Act requires health care institutions to provide written information to patients concerning their rights to make decisions about their care, including the right to refuse treatment and to formulate an advance directive.
• Uniform Anatomical Gift Act provides the foundation for the national organ donation system.
• Omnibus Budget Reconciliation Act (1986) altered the way health care is provided to older adults.

State Statutes Affecting Nursing Practice

• Nurse practice acts are state laws intended to protect citizens, make nurses accountable, and assure that care is consistent with best practice within the scope and standards of nursing.
• Licensure and nurse licensure compact are components of nurse practice acts.
• Health care acts and informed consent ensure that patients receive an explanation of the procedure, names and qualifications of people performing and assisting in the procedure, description of serious harm, alternative therapies, and the right to refuse the procedure or treatment.
• Good Samaritan laws limit liability and offer legal immunity if a nurse helps at the scene of an accident.
• Public health laws affect individuals, populations, and communities, and are intended to improve the health of people.
• Termination of pregnancy laws vary by state, and nurses should know the law in their state related to termination of pregnancy before working in this area of practice.
• Physician-assisted suicide laws vary by state, and nurses should know their state's laws and ensure that their practice falls within the laws' requirements.
• The Uniform Determination of Death Act determines actual death.

Nursing Workforce Guidelines

• Staffing and nurse-to-patient ratios, nursing assignments, patient abandonment, nurse delegation, and nursing students are components of nursing workforce guidelines.

Legal Implications and Reducing Your Legal Risks

• Torts are civil wrongful acts or omissions of care made against a person or property.
• Quasi-intentional torts are acts in which a person may not intend to cause harm to another but does.
• Unintentional torts arise when a person is harmed and the person inflicting the harm knew, or should have known, that these actions were less than the accepted scope and standard of practice.
• Negligence is conduct that falls below the generally accepted standard of care of a reasonably prudent person.
• Malpractice is a type of negligence committed by professionals.
• Standard of proof is what a reasonably prudent nurse would do under similar circumstances in the geographical area in which the alleged breach occurred.
• Malpractice insurance is a contract between an insurance company and a nurse or employer that is intended to cover costs incurred when a patient sues the employer and/or the nurse.
• Nurse experts testify about the standards of nursing care as applied to the facts of a case.
• Reducing legal risks involves being aware of the actions taken at the organizational level by employers and remaining involved in the nursing profession.

Nursing Today

• To act professionally, nurses must use critical thinking skills, administer quality patient-centered care, and be responsible and accountable.
• Professional nursing practice involves understanding the scope of practice and how it influences patients' lives, their families, and communities.

Science and Art of Nursing Practice

• Nursing requires current knowledge, practice standards, an insightful and compassionate approach, and critical thinking and clinical judgment.

Benner's Nursing Practice Model

• Novice: Beginner nurse student with no nursing experience.
• Advanced Beginner: Some level of experience, maybe only observational.
• Competent: A nurse with 2-3 years of experience in the same clinical position.
• Proficient: A nurse with more than 2-3 years of experience.
• Expert: A nurse with diverse experience and an intuitive grasp of existing or potential clinical problems.

American Nurses Association (ANA)

• Professional practice incorporates knowledge from social and behavioral sciences, biological and physiological sciences, and nursing theories.
• It also includes ethical and social values, professional autonomy, and a sense of commitment and community.

ANA Standards of Practice

• Also known as the "Nursing Process" – a model for clinical decision making.
• The six steps of the Nursing Process are:
  • Assessment
  • Diagnosis
  • Outcomes Identification
  • Planning
  • Implementation
  • Evaluation

ANA Standards of Professional Performance

• Ethics
• Advocacy
• Respectful and equitable practice
• Communication
• Collaboration
• Leadership
• Education
• Scholarly Inquiry
• Quality of practice
• Professional practice evaluation
• Resource Stewardship
• Environmental Evaluation

Professional Responsibilities and Roles

• Autonomy and accountability
• Caregiver
• Advocate
• Educator
• Communicator
• Manager

Career Development

• Clinician
• Advanced Practice Registered Nurses (APRNs)
  • Clinical nurse specialist
  • Nurse practitioner
  • Certified nurse-midwife
  • Certified registered nurse anesthetist
• Nurse Educator
• Nurse Administrator
• Nurse Researcher

Historical Influences

• Nurses respond to patients' needs and participate in determining best practices.
• Knowledge of the history of the nursing profession increases understanding of the social and intellectual origins of the discipline.

Florence Nightingale

• Established first nursing philosophy (Nursing Theory) based on health maintenance and restoration.
• Organized first program for training nurses.
• First practicing epidemiologist.
• Improved sanitation in battlefield hospitals.
• Practices remain a basic part of nursing today.

Civil War to the Beginning of the Twentieth Century

• Clara Barton – Founder of American Red Cross
• Dorthea Lynde Dix – Organized hospitals during the Civil War
• Mary Ann Ball (Mother Bickerdyke) – Helped Dix
• Harriet Tubman – Underground Railroad Movement
• Mary Mahoney – First educated African American nurse
• Isabel Hampton Robb – ANA, American Journal of Nursing
• Lillian Wald – Opened the Henry Street Settlement
• Mary Brewster – Opened the Henry Street Settlement

Twentieth Century

• Movement toward scientific, research-based practice and defined body of knowledge.
• Nurses assumed expanded roles.
• 1906: Mary Adelaide Nutting was instrumental in moving nursing education into universities.
• 1920s: Nursing specialization began.
• 1990: ANA established Center for Ethics and Human Rights.
• 1994: University of Washington Medical Center became the first Magnet-designated organization.

Twenty-First Century

• Nurses are revising nursing practice and school curricula to meet the ever-changing needs of society.
• Aging population
• Cultural diversity
• Bioterrorism
• Emerging infections
• Disaster management

Contemporary Influences

• Importance of nurses' self-care
• Health care reform and costs
• Demographic changes
• Medically underserved

Trends in Nursing

• Evidence-based practice
• Quality and Safety Education for Nurses (QSEN)
• Impact of emerging technologies
• Genomics
• Public perception of nursing
• Impact of nursing on politics and health policy

Quality and Safety Education for Nurses (QSEN)

• Patient-centered care
• Teamwork and collaboration
• Evidence-based practice
• Quality improvement
• Safety
• Informatics

Professional Registered Nurse Education

• Prelicensure: 2-year associate's degree or 4-year bachelor's degree
• Graduate education: Master's degree, advanced practice RN, and doctoral preparation
• Continuing and in-service education

Nursing Practice

• Nurse Practice Acts (NPAs) oversee the scope of nursing practice and regulate it to protect public health, safety, and welfare.
• Licensure and certification: NCLEX-RN examination and certification requirements vary.

Evidence-Based Practice (EBP)

• EBP is a problem-solving approach to clinical practice that combines the best evidence with a clinician's expertise, patient preferences and values, and health care resources in making decisions about patient care.
• The best scientific evidence comes from well-designed, systematically conducted research studies found in scientific, peer-reviewed journals.

Steps of Evidence-Based Practice

• Cultivate a spirit of inquiry: constantly questioning current practices leads to consistent use of EBP.
• Ask a clinical question in PICOT format: P (Patient population of interest), I (Intervention of interest), C (Comparison of interest), O (Outcome), and T (Time).
• Search for the best evidence: sources include agency policy, procedure manuals, quality improvement data, existing clinical practice guidelines, and journal articles.
• Critically appraise the evidence: synthesize or combine findings, consider the scientific rigor of the evidence, and determine its application in practice.
• Integrate the evidence: apply research in plan of care, educate about change, and incorporate into policies and procedures.
• Evaluate the outcomes of the practice decision or change: determine effectiveness, make modifications, and discontinue if needed.
• Communicate the outcomes of the evidence-based practice decision: share with clinical staff, nursing practice council, and professional conferences.

Scientific Method

• Make an observation
• Ask questions and gather information
• Analyze the literature and form a research question or hypothesis
• Conduct a study using scientific rigor
• Analyze the data and draw conclusions

Types of Research Studies

• Quantitative research: experimental, non-experimental, and surveys
• Qualitative research: inductive reasoning

Nursing Research

• A way to identify new knowledge, improve professional education and practice, and use resources effectively
• Translation research phases: preclinical and animal studies, Phase 1-5 clinical trials, and outcomes research
• Outcomes research: focuses on benefits, risks, costs, and holistic effects of a treatment on patients
• The conduct of nursing research: allows nurses to study nursing questions and problems in greater depth within the context of nursing.

Performance Improvement (PI)

• A formal approach for the analysis of health care-related processes
• Reviews how existing interventions within a process function
• PI combined with EBP is the foundation for excellent patient care and outcomes.
• Performance improvement programs focus on processes or systems that significantly contribute to outcomes.

The Relationship Among EBP, Research, and PI

• Although EBP, research, and PI are closely related, they are separate processes.
• EBP: uses information from research and other sources to determine safe and effective nursing care with the goal of improving patient care and outcomes.
• Research: systematic inquiry answers questions, solves problems, and contributes to the generalizable knowledge base of nursing.
• PI: improves local work processes to improve patient outcomes and health system efficiency; results usually not generalizable.