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)
1. Autonomy: the right of the patient to make ones own decision
- Example: Religious Practices & Cultural Beliefs (Blood Transfusion & Organ Donation)
2. Veracity: the intention to tell the truth
- Never give false reassurance to another person
3. Beneficence versus Non-malfeasance
a. Beneficence : duty to do good
b. Non-malfeasance: duty to avoid evil
4. Confidentiality: social contract in keeping ones privacy


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.
S- Sexually abused minors & adolescents


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, politi-
cal 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 - any professional misconduct which
person to perform an act or omission involves any conduct that exceeds
to do something that a reasonable prudent the limits of ones professional stan-
person would do or not do. dards means going beyond the context
- Most common unintentional tort or scope of allowed nursing practice
- Failure to observe the protection of ones resulting to injurious or non-injurious
interest, the degree of care, and vigilance consequences.
of circumstances. - stepping beyond ones authority

Example: Example:
a. Incorrect sponge counts a. prescribing drugs
b. burns: heating pads ,solutions & steam b. giving anesthesia
vaporizers c. doing surgery
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

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

B- breach of duty was the cause of the P- professional SPECIFIC standards of care
plaintiffs injury is required
R- Real or actual proof injuries R- required obedience
to the standards of care
O- owed specific nursing duty E- exceeds the limits of the standards of care
D- defendant breach the duty

Intentional Torts
Assault Battery
-Mental or physical threat -physical harm through willful touching of
person or clothing without consent.
Example Example
a. threatening or attempting to do a. actually touching or wounding a person
in
violence to another offensive manner
b. forcing a medication or treatment b. hitting or striking a client
when the patient doesnt want it c. immediately injecting a surgical needle
c. threatening children to take the medication 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. RESTRAINTS SHOULD NOT BE USED PRN!!!
2. Informed consent and a Doctors order is needed to use restraints.
3. 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. DONT ASK PERMISSION IF THE PATIENT HAS AN ALTERED LEVEL
OF CONSCIOUSNESS!!!
7. 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 co-
worker to witness the record. RESTRAINTS OF ANY DEGREE MAY CONSTI-
TUTE FALSE IMPRISONEMENT. Freedom from any UNLAWFUL restraint is a
Basic human right protected by law. In July 1992 the FDA (Food and Drug Admi-
nistration) 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. Identifying and defining basic tasks.
2. Delegation of authority and assigning responsibility
3. 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. Solid Horizontal Line represent same positions but different functions.
d. 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, V-
President, Chief
Nursing Officer
Middle
Level
Managers
1. They
conduct day-day
operations with
some
involvement,
long term
planning and
policy making.
Head Nurse,
Department Head,
Unit
Supervisor/Manager
First Level
Managers
1. Concerned
with specific unit
workflows.
2. Deals with
immediate day-
day problems.
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. Shortens the administrative distance from the top to the lower
2. Solutions to problems are easily carried out/fast response
3. 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. Preparing to Recruit types and number of personnel
2. 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. Regulatory Requirements mandated by RA
3. 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 Advantage Disadvantage
Case Method/Total Patient
Care
- oldest method of patient
care delivery. It is taking
care of individualized
patient.
Provides nurses with high
autonomy and responsibility
Assigning patients is simple
and direct
Holistic care given patients
Each nurse can modify the care regimen
which can cause confusion for the patient
Requires highly skilled personnel
Costly
Unsafe if nurse is unprepared
Functional Method
- divides the nursing work
into functional unit that is
then assigned to members
- nurse has a special task
Increases individual aptitude
and experience improves
Time saving
Increases productivity
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
their own expertise
Provides patient centered
care
Patients nursing care needs
are identified and met through
NCP
May lead to fragmented care
Finding time for team conference and care
planning may be difficult to attain
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. Patient type and acuity
2. Number of patients
3. Experience of Staff
4. 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. Communication
2. Delegation
3. Motivation
4. Coordination
5. 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 Definition
Upward Subordinates to superior
Downward Superior to subordinates
Horizontal Message flow in same hierarchal positions
Diagonal Managers interact with personnel and managers of different departments or groups
Outside 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. Does not trust
2. Fear of mistake
3. Fear of criticism
4. 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. Managers believe that they can do the work faster and better
b. 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. Managers who are lazy
b. 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. Plan ahead
2. Identify necessary skills and levels
3. Select most capable personnel
4. Communicate goal clearly
5. Empower the delegate
6. Set deadlines and monitor progress
7. Model the role and provide guidance
8. 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. Restriction autocratic coercive style that uses indirect and obstructive expression of conflict.
3. 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. Majority rule unanimous decision
6. 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. Win-Win Strategy focuses on goals and attempts to meet the needs of both parties.
9. 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