According to the American Nurses Association (ANA), “the Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population or specialty are expected to perform competently” (2010, p. 2). The ANA further states that the standards can change as the dynamics of professional nursing evolve and that specific clinical circumstances or conditions might affect the application of the standards at any given time (ANA, 2010). In 2010, ANA endorsed WOC nursing as a specialty practice (Wound, Ostomy and Continence Nurses Society, 2010). Therefore, it is important for WOC nurses to be aware of the standards and scope of practice as a foundational guide to excellence in practice and to recognize the legal implications of standards and definitions of the scope of practice.
The legal aspects of nursing have an impact on the manner in which care is delivered to patients by nurses. Legal concerns shape the environment in which nursing is practiced and determine how documents are kept or shared. Ultimately, nurses and the nursing care they provide are judged based on a legal definition for the standard of care for nurses. Written “standards of care” and “guidelines” are available as resources for determining how nursing care is to be delivered and the quality of care. However, the legal definition of the standard of care for nurses is not a “guideline” or a “policy” set by any one individual or institution. Rather, it is the embodiment of collective knowledge for what is required of the average nurse and sets the minimum criteria for proficiency.
Federal and state laws also impact the manner in which nursing is practiced. Health care is one of the most regulated sectors of commerce, and much of the regulation of the industry comes from federal and state laws. Other regulatory requirements are imposed by various government-sponsored programs, such as Medicare, or are self-imposed to conform to various other government and private initiatives. Due to the potential for civil and criminal liabilities and sanctions in regard to health care, nurses should be familiar with key statutes and regulations regarding the delivery of patient care (Carroll, 2006).
This chapter is meant to provide an overview of the legal standard of care for nurses and its impact upon nursing practice. Nursing malpractice is described and suggestions are provided for minimizing risks for malpractice suits. The chapter also includes an overview of laws that affect the practice of nursing.
In previous decades, prior to the growth of professional nursing practice, nurses were judged by the same standard of care as the ordinary man or woman. A nurse was not considered a professional who delivered specialized care. Often, if nursing notes were written, they were not considered part of the medical record.
Over time, the scope of nursing practice has expanded, technologies have changed, and nurses have elected higher levels of education. With these changes, there was a change in the manner in which the standard of care for nurses was viewed, that respected nursing special body of knowledge and expertise. With the growing body of nursing knowledge comes more responsibility, not just in the use of advanced technology but also in the manner in which nursing care is delivered.
The legal notion of the standard of care for nurses, much like the Constitution, is a living concept. It is broad and allows room for interpretation and expansion as the practice of nursing and the environment of nursing practice evolve and change. Guidelines and policies, on the other hand, are static and provide more specific information regarding the delivery of certain aspects of nursing care as interpreted by individual institutions or organizations.
In 1975, nurses were finally identified as professionals worthy of the protection of the law afforded to other medical professionals, when statutory protection was afforded to nurses who might be sued on the basis of nursing practice. Since July 9, 1975, a negligence claim against a nurse has been characterized as malpractice (Chase v. Sabin, 1994). This meant that nurses were identified as providing specialized care and treatment based upon the principles of nursing. A nurse's knowledge and the delivery of nursing care were no longer compared to the standard of an ordinary man or woman. In Michigan, the Revised Judicature Act of 1961 states that a civil action for malpractice may be maintained against any person professing or holding himself or herself out to be a member of a state licensed profession.
In the past, physicians or other health care professionals could offer their opinions on the standard of care for nurses. No longer can physicians testify about the standard of care for nurses. Only a nurse is considered to have the special body of knowledge, education/training, and experience to provide testimony regarding what the average nurse would do, under the same or similar circumstances, for a patient presenting in the same or similar manner.
Protection for nurses is afforded by statutes in each individual state. Individual states determine and interpret the laws. Additionally, the state courts interpret statutes and produce written opinions explaining the interpretation of the law.
In some states, nurses are protected under statutes governing the “statute of limitation.” The statute of limitation is the period of time following an alleged injury during which a plaintiff (injured party) may bring his or her claim. If a nurse is subject only to ordinary negligence, the statute of limitation may be lengthened significantly. Generally, the statute of limitation for medical actions is 2 years from the date of the incident alleged to be the cause of the injury, although this may vary in pediatric or wrongful death cases. Statutes of limitation also vary from state to state.
As stated previously, nurses are protected by laws allowing only nurses to testify regarding what a nurse would do in a similar situation with a similar patient. However, some states, such as Michigan, still maintain a local standard of care for nurses. As a result, the nursing standard of care in Michigan is that of a reasonable nurse in the same or similar situation, with the same or similar patient, in Michigan. However, as nursing practice expands and advanced practice nurses become more specialized and are nationally certified, there is a shift toward a national standard of care for nurses in advanced practice.
The legal definition of the standard of care for nurses is a broad statement. It is unlikely to be found in the state statutes, public health codes, or nurse practice acts. Rather, the standard of care is established by the average reasonable nurse, practicing in the same or similar circumstances and delivering care to the same or similar patient. Hospital/facility policies or other guidelines do not necessarily define the standard of care for nurses as it might be defined in the legal environment. An institution's guidelines are generally more specific about the care and treatments provided in that particular institution.
Nurses are considered to have a general nursing knowledge rather than thought of as specialists, such as physicians might be. It is important for nurses to understand that the standard of care for nurses is only that of the reasonable, ordinary nurse and it is the standard of care at the time of the incident that is applicable. Additionally, if testimony about nursing is to be provided, it must be from a nurse with experience in the area of nursing in question. For example, a wound care nurse would be held to the standard of a reasonable wound care nurse, practicing under the same or similar circumstances, in the year the incident occurred.
More specifically for a wound care nurse, the standard of care would be that of an average nurse practicing in the area of wound care and delivering nursing care to a same or similar patient under the same or similar circumstances. There is a trend toward a national standard of care for those nurses whose credentials indicate that they are certified by a national association of nurses.
In cases of advanced practice nurses such as a certified RN anesthetist (CRNA) or nurse practitioner (NP), the standard of care would be for a CRNA or NP. In general, advanced practice nursing requires specific qualifications including an advanced degree in a specific area of expertise. Advanced practice nursing may also require certification by a national association and specific licensing by the state through the board of nursing. The state boards of nursing may define the nursing scope of practice through statutes.
The legal standard of care for an advanced practice nurse would be that of an average and reasonable advanced practice nurse. Specifically, the legal definition of the standard of care would be that of an average and reasonable advanced practice nurse, practicing in his or her area of expertise and caring for a same or similar patient under the same or similar circumstances. Nurse practitioners may practice in dependent or independent roles in many different settings. If the NP is associated with an institution, he or she should evaluate the employment contract to determine if he or she is classified as an employee or an independent contractor. Employee status will impact decisions regarding whether to purchase individual malpractice insurance.
Malpractice is negligence, misconduct, or breach of duty by a professional that results in injury/damage to a patient (Reising & Allen, 2007). According to Reising and Allen, common malpractice claims arise against nurses when nurses fail to:
To prove malpractice, all 4 of the following elements must be proven by the plaintiff: the nurse had a duty to the patient, the nurse breached the duty, a patient injury occurred, and there was a causal relationship between the breach of duty and the patient injury (Reising, 2012). Therefore, in determining if malpractice has occurred, these 4 elements must be carefully considered. First, did the nurse have a duty to the patient? This means that the nurse was actively engaged in providing nursing care to the patient. Second, was there a breach of that duty? In other words, did the nurse commit an act or omission in the act of taking care of the patient and did that act or omission result in harm to the patient?
The third element is “proximate cause.” The question here is whether the action or omission caused any harm to the patient. If the action did not result in harm or injury, there was no malpractice. Finally, the fourth element is damage. What harm occurred as a result of the action of omission during the delivery of nursing care? A nurse might have a duty to a patient and commit an action or omission during the course of nursing care, and it might not constitute malpractice if the action or omission did not result in harm to the patient.
In the following case, examples of malpractice related to wound care are presented. An 80-year-old patient was admitted to a nursing unit, and a wound was identified on her right heel. Although care was provided for the wound on her heel, the nurse failed to complete a head-to-toe skin assessment and assess the patient's risk for pressure ulcer development. As a result, a large pressure ulcer developed on the sacrum. When this wound was finally identified, it was a stage IV pressure ulcer and took several months of additional treatment for healing, including nursing home care.
An analysis of the case would be as follows: Did the nurse have a duty? Yes. She was actively engaged in delivering nursing care to the patient. Did the nurse breach the duty? Yes. The nurse failed to completely assess the patient and, as a result, a sacral ulcer developed. Was the nurse's failure to completely assess the patient a cause of harm to the patient? Yes. At admission, the patient did not have skin breakdown on the sacrum. The wound was discovered upon transfer to another facility.
Finally, was there damage? Yes. A wound developed on the sacrum, and damage included the economic costs for additional hospital and nursing home care, a decline in mobility, and emotional distress.
In fact, this was an actual case that resulted in a settlement. The key point is to protect your patients and yourself by implementing the complete nursing process and thorough documentation.
Nurses should be cognizant of legal risks in providing care. Reising (2012) suggests that the following actions can help minimize a nurse's risk of being sued for malpractice:
How a lawsuit for medical malpractice is initiated may differ in each state. However, whether you are served with a complaint or a letter of intent to sue, your first response should be to contact your supervisor or employer and/or legal department: They will help you determine insurance coverage. Never speak to a representative of the plaintiff (ie, the person who is bringing the lawsuit).
After you have contacted the legal department, you will be assigned an attorney to guide you through the case. Do not discuss the case with anyone other than your employer or legal representative. An attorney will contact you for an interview and will likely provide you with a copy of the medical records in question for review. The nurse is a key partner in the defense of the case, and the nurse's knowledge of the medical record is very valuable.
If a lawsuit results in a judgment against a nurse, the state may require that the judgment be reported to the state board of nursing. Sometimes, there is an investigation by the board of nursing into the facts of the case, necessitating legal representation of the nurse during the investigation. However, most actions do not result in specific judgments against nurses.
Many nurses ask whether they should carry their own malpractice insurance in addition to that provided by their employer. First, it is important to understand the amount of insurance coverage that the employer provides and what is covered. A staff nurse working in an institution such as a hospital is unlikely to need additional coverage, unless he or she practices outside of the hospital (eg, works at first aid stations at baseball tournaments; works at camps not affiliated with the hospital). However, a nurse with an independent practice or who is identified as an independent contractor may require individual coverage.
In addition to nursing malpractice, there are multiple federal and state laws and regulations that impact the practice of nursing and may impose liability. The following discussion presents a brief overview of some of these: state/federal statutes governing privacy, the use/disclosure of a patient's protected information, peer review for negligent or unprofessional conduct, patients' rights to make decisions about their medical care, conditions of participation for Medicare/Medicaid reimbursement, requirements for reporting suspected/actual elder or child abuse, and professional practice acts and licensure.
The Privacy Act (1974) regulates the collection, use, maintenance, and distribution of personally identifiable information about individuals that is kept in the record systems of federal agencies. This act impacts all health care providers and health care plans that transmit health care information in electronic form. It has been described as a consumer protection act.
Congress enacted the Health Insurance Portability and Accountability Act (HIPAA, 1996) to limit the ability of an employer to deny health insurance coverage to employees with preexisting medical conditions. The law also directed the US Department of Health and Human Services (USDHHS) to develop privacy rules, including, but not limited to, the use of electronic medical records. In recent years, this has expanded to include other considerations for electronic transmission of health care information.
Among other things, HIPAA gives individuals the right to obtain their own medical records and request amendments to their medical records (USDHHS, n.d.-a) and allows the individual to learn where the records have been disclosed (USDHHS, n.d.-b).
HIPAA provides that individuals must be provided with medical records within 30 days of a request. It also prohibits release of personal health information without permission. Generally, a HIPAA-compliant, signed authorization must be presented in order to obtain medical records. An individual who believes his or her health care information has been inappropriately exchanged may file a complaint with the provider or USDHHS Office for Civil Rights. The provider can be liable for both civil and criminal penalties. Recently, the rule has been expanded to hold individuals liable to the consumer. This becomes especially important when the manner and number of ways that information is exchanged across the Internet are considered.
As health care and technology rapidly grow and expand, new issues will occur. Interpretation of statutes will be challenged and can change, laws will be revised, and new legislation can be introduced. There are significant penalties for failure to meet HIPAA requirements. Previously, penalties were limited to the institution. Recently, new federal laws have been enacted that allow individuals to be held accountable for breaches of the Privacy Act. Therefore, nurses need to keep up with the changes that affect their nursing practice. Resources for information regarding legal/regulatory updates include the professional journals and nursing organizations. In addition, in a hospital-based practice, the departments for risk management, quality, and/or legal affairs can help the nurse keep abreast of changes.
Social networking can have a significant impact on health care practice. Society has become adept at using computers, cell phones, Facebook, and Twitter for exchange of information. However, the ease of exchange of information does not exempt the health care provider from obtaining a HIPAA-compliant consent form. There have been cases of practitioners sharing an interesting case or sharing health care information over social networking sites. Without the patient's consent, it is not appropriate to share information, especially when the information is not shared on a secured network and is out there for the world to see. This can result in civil and criminal penalties. Therefore, it is important to be aware that a HIPAA-compliant authorization must be obtained for any exchange of health care information.
The Health Care Quality Improvement Act (1986) encourages hospitals, state licensing boards, and professional societies to identify and take corrective action for health care workers who may be found by peer review to be engaged in negligent or unprofessional conduct. This act encourages peer review, and, if performed correctly, it might provide immunity from civil liability. Many states encourage “peer review” and internal investigations of incidents that have resulted in harm to patients and provide statutory protection of peer review activities within an organization. In addition, hospitals/facilities and personnel have a strong interest in providing quality care and preventing future harm to their patients through such review activities.
The federal Patient Self-Determination Act (PSDA, 1990) mandates that individuals receiving medical care must be given written information about their rights under state law to make decisions about medical care, including the right to accept or refuse medical or surgical treatment (Crego, 1999). The law applies to all health care facilities providing services and receiving federal reimbursement, including nursing homes, home health agencies, clinics, and hospitals. The essence of the legislation was to empower the public with the right to make end-of-life decisions. The PSDA defines the rights of competent patients to make binding, legally enforceable decisions about their health care preferences that are to be followed should they later become unable to express their wishes. This includes assigning a patient care advocate for medical decision making and endorsing a witnessed and notarized living will for end-of-life decisions. Many state legislatures have added additional legal steps and actions that need to be taken for end-of-life decisions that may vary greatly from state to state.
There are distinct requirements that must be met for a provider to participate in the Medicare program (ie, conditions of participation [COP]). These COP are found in various codes of federal regulations (C.F.R.). They include COP for hospitals, COP 42 C.F.R., 482 (2008); home health care agencies, COP 42 C.F.R., 484 (n.d.); comprehensive rehabilitation facilities, COP 42 C.F.R., 485 (n.d.); and requirements for long-term care facilities (Legal Information Institute, n.d.).
In addition, the Office of the Inspector General (2000) published its Compliance Program Guidelines to reduce the incidence of pressure ulcers and malnutrition in long-term care facilities. These are especially important issues for WOC nurses who provide or oversee care in these facilities. With an increasingly aging population, these regulations are important, especially because a condition of payment for services by Medicare and Medicaid requires adherence to the Compliance Program Guidelines. Moreover, failure to comply may result in criminal and civil liability as well as monetary penalties.
Elder abuse has become a growing problem. Various states have mandatory requirements for reporting elder abuse and neglect. To encourage reporting, many states have enacted immunity provisions protecting individuals who report abuse and/or neglect from civil liabilities. Also, some states, in addition to having mandatory reporting requirements, include penalties for individuals who fail to comply. Nurses are often observers of abuse or neglect and should be aware of reporting requirements.
The National Center on Elder Abuse (NCEA, n.d.), directed by the US Administration on Aging, is committed to helping national, state, and local partners to be fully prepared to ensure that older Americans live with dignity, integrity, and independence and without abuse, neglect, and exploitation. The NCEA is a resource for policy makers, social services, health care practitioners, the justice system, researchers, advocates, and families. A visit to the Web site (http://www.ncea.aoa.gov) provides phone numbers for each state where abuse can be reported.
WOC nurses are in a unique position to identify and report suspected child abuse. Children who are chronically ill or require wound care and/or ostomy care are at risk for abuse. Since the early 1970s, federal and state legislation has been enacted to protect children from abuse. Those who report abuse are generally protected from liability.
Although federal statutes have been enacted regarding prevention of child abuse, it is largely the states that administer these laws and take action. For example, according to the Child Protection Law (1975), the state of Michigan requires reporting of any suspected abuse and does not allow a health care practitioner to make a medical judgment as to the cause of the abuse. Rather, any suspected child abuse must be reported orally and a written report provided within 72 hours. Information may be provided to the investigators in the written report regarding the suspected cause of abuse or neglect.
For each group of health care professionals, licensed by the state, laws and regulations are in place that define the scope of practice and outline the oversight authority vested in their professional regulatory boards. Most states have a nurse practice act that serves as a general guideline regarding the practice of nursing and licensure requirements. Generally, the scope of nursing practice is defined for licensed practical nurses, RNs, and advanced practice nurses. The scope of practice of an individual practitioner is an important consideration because practicing outside of the scope of nursing can open the individual to civil liability and censorship by the board of nursing.
The scope of practice of nurses can also be further defined by hospital policies and procedures. The policies and procedures of individual organizations should show evidence of compliance with licensing board requirements and legislative requirements, as well as with guidelines established by such agencies as The Joint Commission. National and state nurse associations are other resources that provide guidelines for the practice of nursing.
In this chapter, a general overview of the legal aspects of nursing has been presented. The legal definition of the standard of care for nurses is defined as that of what a reasonable and prudent nurse would do when caring for a same or similar patient in the same or similar circumstances. The reason for having such a general definition is to allow for changes in the manner in which nursing is practiced. Guidelines and hospital policies and procedures are more specific but may change from year to year. As a result, the nursing care provided to a same or similar patient under the same or similar circumstance in one year is likely to be different from care in previous or later years. For specific legal issues or questions, nurses are encouraged to seek guidance from their facility's legal or risk management departments whose personnel are versed in local laws and regulatory requirements.
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