Legal Aspects of Nursing Notes I

Definition of Terms Board of Registered Nursing Each state has a Board of Registered Nursing organized within the executive branch of the state government. Primary Responsibilities of the BRN include the administration of the Nurse Practice Act as applied to registered nurses. Authorization to Practice Nursing To legally engage in the practice of nursing, an individual must hold on an active license issued by the state in which he or she intends to work. Nurse Practice Act A series of statutes enacted by each state legislature to regulate the practice of nursing in that state. Topics that are included are the following a. scope of nursing, education, licensure, grounds for disciplinary actions & related topics. a. Provides legal authority for nursing practice including delegation of nursing tasks. b. Many boards of nursing also provide decision and delegation checklist. c. Set educational requirements for the nurse distinguishing Nursing Practice from Medical Practice & defines the Scope of Nursing. ANA (American Nurses Association) of 1980 Incorporates the following elements that demonstrate in a nurse: a. Human dignity & uniqueness of individual regardless of health problems & socio-economic status b. Maintain patients right for privacy & confidentiality c. Maintain competence through ongoing professional development & consultation. Ethical Principles of Bio-ethics A philosophical field that applies ethical reasoning process for achieving clear & convincing reasons to issues & dilemmas ( conflicting between two obligations) Autonomy: the right of the patient to make ones own decision - Example: Religious Practices & Cultural Beliefs (Blood Transfusion & Organ Donation) Veracity: the intention to tell the truth Never give false reassurance to another person Beneficence versus Non-malfeasance Beneficence : duty to do good Non-malfeasance: duty to avoid evil Confidentiality: social contract in keeping ones privacy

1. 2. 3. a. b. 4.

Standards of Care Guidelines for determining whether nurses have performed duties in a appropriate manner & guidelines in which the nurse should practice Patients Bill of Rights Right for appropriate treatment that is most supportive & least restrictive Right to individualized treatment plan, subject to review & treatment Right to active participation in treatment with the risk and side effect of all medications and treatment Right to give and withhold consent/contracts Contracts & Consent: it is the meeting o the minds between two or more persons whereby one binds himself with respect to the other to give something or to render some service. Pre-requisites of a Valid Consent and Contract (OPEN- V)

O- Opportunity to ask questions (possible consequences of the procedure) P- Physically & Mentally Competent & Mature ( 18 years old & up ) E- Explained the Procedures & Treatment Specifically N- Nothing should be misunderstood by the patient (the patient should not be allowed to sign the informed consent if she / he is pre-medicated or under the influence of alcohol or drugs or mentally incapacitated V-Voluntary Made (absence of force, fraud, deceit or duress ( force)

Exceptions to an Informed Consent (MEMO-S) M Married & Mature Minors E- Emancipated minors (to release a child from the control of his parents) Emergency Cases

M-

Minors seeking birth control or pre-natal treatment O- Over specific age (ex. 12 years old & above) may give consent for STD, HIV testing, AIDS treatment, drugs & alcohol treatment WITHOUT parents consent. Sexually abused minors & adolescents

S-

Right to refuse Treatment 1. Advance Directives: Legal, written or oral statements made by a mentally competent person about treatment. In the event the person is unable to make these determinations, a surrogate decision-maker can do so, example: sudden serious illness. Characteristics of Advance Directives 1. allows clients to participate in choosing health care providers (Choosing his / her own nurses & doctors) 2. allows also in choosing the type of medical treatments the client desires. 3. Allows clients to consent or refuse treatments The Patient Determination Act of 1990 (PSDA) is a federal law that imposes on states and providers of health care certain requirements concerning Advanced Directives as well as clients right under law to to make decisions concerning medical care. The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1990 - Medical Screening of patients cannot be delayed until insurance coverage or the ability to pay has been determined. This is to assure that the patients are not denied care based on their ability to pay , patients must be medically screened & stabilized before their ability to pay is determined. Failure of a Hospital to comply may result in denial of Medicare funding. Example: All women patients having labor contractions must be medically screened & stabilized before transfer to another facility. Whether it is obvious that the patient is in labor or not, the patient must be medically screened & examined before the decision is made to transfer the patient to another facility. The emergency department does not have the right to refuse treatment to a patient before medically screening the patient.

- It does not address payment for services as part of the admission procedure. It only addresses medical screening & stabilization of patients before transport or the determination of ability to pay for services rendered. a. Living Will: legal document stating person does not wish to have extra-ordinary life saving measures when not able to make decisions about his own care. -applicable FOR LIFE SAVING TREATMENT ONLY. Example: CPR, antibiotics & dialysis will be used or not b. Durable Power of Attorney: legal document giving designated person authority to make health care decisions on the clients behalf when the client is unable to do so. Right to obtain Advocacy Assistance Patient Advocate: is a person who pleads for a cause or who acts on the clients behalf. Example: nurse Goal of Advocacy: help client gain greater self-determination & Encourage freedom o choices, increase sensitivity & responsiveness of the health care, social, political systems to the needs of the client. Example: advocates for HIV client rights for proper treatment & job opportunities

Legal Aspects of Nursing Notes II

CRIMES AFFECTING NURSES I. Crime - Act committed in violation of social law.

a. Tort (fraud, negligence & malpractice) - Legal wrong committed against a person, his rights & property.

1. Fraud misrepresentation of fact with intentions for it to be acted on by another person ( such as falsifying graduate nursing programs)

2. Negligence 3. Malpractice

Negligence

versus

Malpractice

Definition:

Definition:

- Unintentional failure of an individual person to perform an act or omission to do something that a reasonable prudent person would do or not do. - Most common unintentional tort - Failure to observe the protection of ones interest, the degree of care, and vigilance of circumstances.

- any professional misconduct which involves any conduct that exceeds the limits of ones professional standards means going beyond the context or scope of allowed nursing practice resulting to injurious or non-injurious consequences. - stepping beyond ones authority

Example: a. Incorrect sponge counts

Example: a. prescribing drugs

b. burns: heating pads ,solutions & steam b. giving anesthesia vaporizers c. failure to take & observe appropriate actions forgetting to take vital signs to a newly post operative client. d. Falls: side rails left down, baby left unattended e. loss of or damage to a patients property f. failure or ignore to report to the superiors or clients family g. mistaken identity, wrong medicine, dose & route c. doing surgery

ELEMENTS OF NEGLIGENCE LAWSUIT (B-R-O-D) MALPRACTICE(p-r-e)

ELEMENTS OF

B- breach of duty was the cause of the plaintiffs injury

P- professional SPECIFIC standards of care is required

R- Real or actual proof injuries to the standards of care O- owed specific nursing duty D- defendant breach the duty

R- required obedience

E- exceeds the limits of the standards of care

Intentional Torts Assault -Mental or physical threat Battery -physical harm through willful touching of person or clothing without consent. Example a. threatening or attempting to do in violence to another b. forcing a medication or treatment when the patient doesnt want it c. threatening children to take the medication Example a. actually touching or wounding a person offensive manner b. hitting or striking a client c. immediately injecting a surgical needle without informing the patient about

the said procedure

False Imprisonment - occurs when the person is not allowed to leave a health care facility when there is no legal justification to detain the client. - occurs when restraining devices are used without an appropriate clinical need. - The intentional confinement without authorization by a person who physically constricts another using force , the threat of force or confining structures and or clothing , even without force or malicious intent to detain another without consent in a specified area constitutes grounds or a charge of false person from harming self or others if it is necessary to confine to define one self , others or property or to effect a lawful arrest.

Examples:

a. A Hispanic American patient undergo TAHBSO and has no Medicare or HMO card nor nor any petty cash to pay hospital bills. The nurse put the patient in a room until the relatives of the former arrive to pay the bills.

B. a Hong Kong OFW was suspected of having SARS. The ground duty nurse put the patient in a secluded room without doctors order and checked for other manifestations to confirm the presence of SARS. After 9 hours, it was just an ordinary cough and colds.

c. A client was tested positive for HIV. Nurse Hamilton learned that this is highly contagious & communicable disease. The nurse locked the client inside a room.

Legal aspect regarding Restraints

Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or an extremity. Physical restraints: restrict client movement through the application of a device. Chemical restraints: Medications given to inhibit a specific behavior or movement.

Under Omnibus Budget Reconciliation Act: any client or patient has the right to be free from Physical (such as restraint jackets) and chemical (sedation, psychotropic drugs) restraints Imposed for the purpose o discipline or convenience and should not be required to treat medical or psychiatric symptoms.

Lawful Requirements & Nursing Actions for Using Restraints According to (JCAHO) Joint Commission on ACCREDIATATION OF HEALTHCARE ORGANIZATIONS

1. 2. 3.

RESTRAINTS SHOULD NOT BE USED PRN!!! Informed consent and a Doctors order is needed to use restraints. Doctors orders for restraints should be renewed within a specific time frame

according to the agencies policies. 4. Restraints should not interfere with any treatments or affect the clients health problems. 5. Document the following: Reason for the restraints Method of restraints Date and time of application Duration of use and clients response Release from the restraints (every 30 minutes) with periodic exercise and Circulatory, neurovascular and skin assessment Evaluation of clients response 6. 7. DONT ASK PERMISSION IF THE PATIENT HAS AN ALTERED LEVEL OF CONSCIOUSNESS!!! If the client is unable to give consent to a restraint procedure, then consent of proxy must be obtained AFTER FULL DISCLOSURE OF ALL RISK AND BENEFITS. 8. Use a clove hitch knot so that restraint can be changed and release easily and ensure that there is enough slack on the straps to allow some movement o the body part. 9. Never secure restraints to bed rails or mattress. Secure restraints to parts of the bed or chair that will move with client & not constrict movement.

ALTERNATIVES TO RESTRAINTS

1. Before restraints offer explanations, ask someone to stay with the client, use clocks, calendars, TV & radio ( to decrease disorientation) or any relaxation techniques. 2. Use LESS restrictive methods first. RESTRAINTS should always be the last. 3. Assign confuse and disoriented clients to rooms near the nurses station. 4. Maintain toileting routines & institute exercise and ambulation schedules as the client condition allows.

QUESTION: Can I put restraints on a patient who is combative I there is no order for this? Only in an EMERGENCY, for a limited time (no longer than 24 hours) For the limited purpose of protecting the patient from injury NOT FOR CONVENIENCE OF Personnel. Notify the attending MD immediately, consult with another staff member, obtain patients consent if possible, and get a coworker to witness the record. RESTRAINTS OF ANY DEGREE MAY CONSTITUTE FALSE IMPRISONEMENT. Freedom from any UNLAWFUL restraint is a Basic human right protected by law. In July 1992 the FDA (Food and Drug Administration) issued a warning that the use of restraints is NO LONGER REPRESENTS RESPONSIBLE PRIMARY MANAGEMENT of a clients behavioral problem.

NURSING LEADERSHIP AND MANAGEMENT

ORGANIZING Determine what task are to be done, who is to do these, how the tasks are to be grouped, who reports to whom and what decisions are to be made. It is a form of identifying roles and relationships of each staff on order to delineate specific tasks or functions that will carry out organizational plan s and objectives. Process of identifying and grouping the work to be performed, defining and delegating responsibility and authority and establishing relationships for the purpose of enabling the people to work more effectively together in accomplishing objectives. As a process, it refers to the building of a structure that will provide for the separation of activities to be performed and for the arrangement of these activities in a framework which indicates their hierarchal importance and functional association. The Process Involves: 1. 2. 3. Identifying and defining basic tasks. Delegation of authority and assigning responsibility Establishing relationships

Three forms of authority:

1.

Line authority is a direct supervisory authority from supervisor to subordinates.

a. Chain of Command unbroken line of reporting relationships that extends through the entire organization. The line defines the chain of command and the formal decision making structure. b. Unity of Command within the chin states that, each person in the organization should take orders and reports only to one person. c. Span of Control refers to the number of employees that should be placed under the direction of one leader-manager.

2. Staff Authority authority that is based on the expertise and which usually involvesadvising the line managers.

3. Team Authority is granted to committees or work teams involved in an organizations daily operations. Work teams are group of operating employees who shared a common vision, goals and objectives. Organizational Chart Drawing that shows how the parts of the organizations are link. It depicts the formal organizational relationship, areas of responsibility and accountability and channel of communication. Depicts an organizations structure. ORGANIZATIONAL STRUCTURE Depicts and identifies role and expectations, arrangement of positions and working relationships.

a.

Dotted or Unbroken line represents staff positions/staff authority (advisor to the line managers).

b. Centrality refers to the location of a position on an organizational chart where frequent and various types of communication occur. Determined by organizational distance; those with small organizational distance receive more information than those who are more peripherally located. c. d. Solid Horizontal Line represent same positions but different functions. Solid Vertical Line chain of command form authority to subordinates (line authority)

MANAGERIAL LEVELS Level Scope of Responsibility Examples

Top Level Managers

1. Generally make decisions with the help of a few guidelines or structure. 2. Coordinates internal and external influences.

CEO, President, VPresident, Chief Nursing Officer

Middle Level Managers

1. They conduct day-day operations with some involvement, long term planning and policy making. 1. Concerned with specific unit workflows. 2. Deals with immediate dayday problems.

Head Nurse, Department Head, Unit Supervisor/Manager

First Level Managers

Charge Nurse, Team Leader, Primary Nurse, Staff Nurse

PATTERNS OF ORGANIZATIONAL STRUCTURE 1. Tall/Centralized Structure

Responsible for only few subordinates so there is narrow span of control Because of the vertical in nature, there are many levels of communication Communication is difficult and messages do not get to the top. Workers are boss-oriented because of close contact with their supervisor.

Example of tall organizational structure. 2. Flat/Decentralized Structure

Characterized by few levels and a broad span of control Communication is easy and direct

Advantages: 1. 2. 3. Shortens the administrative distance from the top to the lower Solutions to problems are easily carried out/fast response Workers developed their abilities and autonomy

Disadvantage: 1. Impractical in large organization.

Example of a flat organizational structure. TYPES OF ORGANIZATIONAL STRUCTURE 1. Line Organization/Bureaucratic/Pyramidal

There is clearly defined superior-subordinate relationship ARA and power are concentrated at the top

2.

Flat/Horizontal Organization

Decentralized type Applicable in small organization Nurses become productive and directly involved in the decision making skills Workers become satisfied

3.

Functional Organization

Permits a specialist to aid line position within a limited and clearly defined scope of authority

4.

Ad Hoc Organization

Modification of bureaucratic structure

5.

Matrix structure

Focus on both product and functions Most complex Has both vertical and horizontal chain of command and line of communication

STAFFING Process of assigning competent people to fulfill the roles designated for the organizational structure through recruitment, selection and development, induction and orientation of the new staff of the goals, vision, mission, philosophy etc.

Staffing Process 1. 2. Preparing to Recruit types and number of personnel Attracting a Staff formal advertisement

3. Recruiting and Selecting a Staff interview induction orientation job order pre-employment testing signing of contract Staffing Pattern plan that articulates how many and what kind of staff are needed/shift or per day in a unit or in a department. 2 ways of developing a staffing pattern

1.

Determine the # of nursing care hours needed/patient

Generating the full time equivalents of an employee 2. Determine the nurse-patient ratio in providing nursing care

FTE measure of work committed of full time employee 1.0 FTE = works 5 days/week, 8 hours/day 0.5 FTE = part time employee who works 5 days/2 weeks CONSIDERATIONS IN STAFFING PATTERN 1. Benchmarking

Management tool for seeking out the best practice in ones industry so as to improve ones performance. Process of measuring products, practices and services against best performing organization as a tool for identifying desired standards of organizational performance. 2. 3. Regulatory Requirements mandated by RA Skill Mix percent or ratio of professionals to non professional

Ex: 40 FTE (20 RN + 20 non RN) = 50% RN mix 4. Staff Support staff support in place for the operations of the units or department.

5. Historical Information review of any data on quality or staff perception regarding the effectiveness of the previous staffing pattern PATIENT CLASSIFICATION SYSTEM (PCS) Measuring tool used to articulate the nursing workload for specific patient or group of patients over a specific time.

Patient Acuity measure of nursing workload that is generated for each patient.

Patient care is classified according to: 1. Self care or minimal care patients are capable of carrying ADL, e.g., hygiene, meals etc.

2. Intermediate or moderate care requires some help from the nursing staff with special treatments or certain aspects of personal care, e.g., patients with IV fluids, catheter, respirator, etc. 3. Total care patients are those who are bedridden and who lack strength and mobility to do average daily living. Ex: patients on CBR, immediate post-op, with contraptions.

4. Intensive care patients are those who are critically ill and in constant danger of death or serious injury. Ex: comatose, bedridden etc.

MODALITIES OF CARE CASE METHOD/NURSING CARE MODELS/METHODS OF CARE DELIVERY

Model Case Method/Total Patient Care - oldest method of patient care delivery. It is taking care of individualized patient. Functional Method - divides the nursing work into functional unit that is then assigned to members - nurse has a special task

Advantage Provides nurses with high autonomy and responsibility Assigning patients is simple and direct Holistic care given patients Increases individual aptitude and experience improves Time saving Increases productivity

Disadvantage Each nurse can modify the care regimen which can cause confusion for the patient Requires highly skilled personnel Costly Unsafe if nurse is unprepared Can cause confusion on the part of the patient May lead to fragmented care Mutes the nursing process Low job satisfaction May overlook patients priority needs N-P relationship is not fully developed Evaluation of nursing care is poor

Team Nursing - assign staff to teams that are responsible for a group of patients.

Allows members to contribute May lead to fragmented care their own expertise Finding time for team conference and care Provides patient centered planning may be difficult to attain care Patients nursing care needs are identified and met through NCP

Primary Nursing - care delivery models but clearly delineates the responsibility and accountability of a RN and designates RN as a primary provider of care to patients

Increase autonomy on the part of the nurse Increase ARA of the RN Continuous care Increased rapport and trust, establishes therapeutic relationship Improves communication with members of the health team

Unsafe if nurse is unprepared Many RNs may initially lack experience and skill Difficulty in recruiting and retaining enough RNs in times of shortages

SCHEDULING Timetable showing planned work days and shifts for nursing personnel. Issues to consider in scheduling staff: 1. 2. 3. 4. Patient type and acuity Number of patients Experience of Staff Support available to the staff

Shifting Variations Traditional Shifting Patterns 3 shift (8 hr shift) 12 hr shift

 10 hr shift Weekend option Rotating work shift Self-scheduling staff makes their own schedule Permanent work shift Floaters on-call

Forty Hour Week Law based on RA 5901 No work, no pay Entitled to 2-week sick leave and off duty for 2 days Special Holidays with pay

DIRECTING act of issuing of orders, assignments, instructions, to accomplish organizational goals and objectives.

Delegation entails responsibility Assignments no responsibility

Elements of Directing 1. 2. 3. 4. 5. Communication Delegation Motivation Coordination Evaluation

Communication exchange of ideas, thoughts or information through verbal speech, writing and signals

Barriers in communication 1. Physical Barriers

 environmental factors that prevent or reduce the opportunities for communication. Ex: Distance and Noise 2. Social and Psychological Barriers

blocks or inhibitors of communication that rise from the judgment, emotions, social values of people.Ex: stress, trust, fear, defensiveness internal climate (values, feelings, temperament and stress levels) and external climate (weather, timing, temperature, lack of validation to the message). 3. Semantics

words, figures, symbols,penmanship and interpretation of the message through signs and symbols. 4. Interpretations

Defects in communication skills by verbalizing, listening, writing, reading and telephony

Channels of communication Channel Upward Downward Horizontal Diagonal Outside Definition Subordinates to superior Superior to subordinates Message flow in same hierarchal positions Managers interact with personnel and managers of different departments or groups Messages are sent from the team to patients, family and friends to the community

Delegation Act of assigning to someone else a portion of the work to be done with corresponding authority, responsibility and accountability (ARA). According to ANA, it is the trabsfer of responsibilities for the performance of the task from one person to another Much of the work of manager is accomplished by transferring the responsibilities to subordinates

Good Reasons for Delegation

1. Manager delegate routine task so that they are free to handle problems that are more complex or require higher level of expertise 2. Delegate routine task if someone else is better prepared or has greater expertise or knowledge in solving the problems

Managers who do not delegate 1. 2. 3. 4. Does not trust Fear of mistake Fear of criticism Fear of own ability to delegate

Common Errors in Delegation 1. Underdelegating systems from the managers false assumptions that delegation maybe interpreted as a lack of ability on his part to do the job correctly and competently Reasons: a. b. Managers believe that they can do the work faster and better Managers believe that the responsibility may be rejected if delegated

2. Overdelegating subordinates become overburdened which may lead to dissatisfaction and low productivity Reasons: a. b. Managers who are lazy Manager who are overburdened and exhausted

Improper Delegation delegating at the wrong person, time, tasks and beyond the capability of the subordinates. Steps in Effective Delegating 1. 2. 3. 4. Plan ahead Identify necessary skills and levels Select most capable personnel Communicate goal clearly

5. 6. 7. 8.

Empower the delegate Set deadlines and monitor progress Model the role and provide guidance Evaluate performance

Motivation whatever influences our choices and creates direction, intensity, and persistence in our behavior. Supervision guiding and directing the work to be done. It entails motivating and encouraging the staff to participate in the activities to meet the goals and objectives for personal development in making the work better. Coordination arranging in proper order. It creates harmony in all activities to facilitate success of work Conflict Management Conflict internal and external discord that results in from differences in ideas, values or feelings between 2 or more people. It arises because of differences in economic and professional values.

Two Main Types 1. Competitive Conflict 2 or more group the same goal and only one group can attain them

Management: Set Goals 2. Disruptive Conflict takes place in environment filled with anger, fear and stress. There is no mutually acceptable set of rules and the goal of each party is the elimination of each opponent. Conflict Resolution Strategies 1. Use of dominance and Suppression

Win loose strategy Looses feels angry 2. 3. Restriction autocratic coercive style that uses indirect and obstructive expression of conflict. Smoothing Behavior persuades the opponent in a diplomatic way

4. Avoidance Behavior 2 parties are aware of the conflict but choose not to acknowledge or attempt to resolve it. 5. 6. Majority rule unanimous decision Compromising consensus strategy where each side agrees solutions

7. Interactive Problem Solving constructive process in which the parties involve recognized that conflict, assist and openly try to solve the problems

8. 9.

Win-Win Strategy focuses on goals and attempts to meet the needs of both parties. Lose-Lose Strategy neither side wins

10. Confrontation most effective means of resolving the conflict. Resolves through knowledge and reason brought out in an open. 11. Negotiation give and take