Nursing Jurisprudence Exam
Different Burden of Proof
Beyond a reasonable doubt; preponderance of the evidence
Sources of Law
-Constitutional Law: Federal, State -Statutory Law: Federal, State -Common Law -Administrative Law
Types of Torts
-Negligence -Intentional: Assault Battery False Imprisonment -Quasi-Intentional: Defamation, Liable, Slander
Although the board does not require the inclusion of any other designations, with the exception of the specific authorization of advanced practice nurses, the insignia may not contain information other than:
(A) the registered nurse or licensed vocational nurse designation; (B) the nurse's name, certifications, academic degrees, or practice position; (C) the name of the employing facility or agency, or other employer; or (D) a picture of the nurse.
TOC Chapter 303. Nursing Peer Review
Defined by NPA §303.001(5) as the evaluation of: nursing services, the qualifications of a nurse, the quality of patient care rendered by a nurse, the merits of a complaint concerning a nurse or nursing care, and a determination or recommendation regarding a complaint.
Disciplinary Action by the BON
Denial of an individual's application for a license, license renewal, or temporary permit; A written warning; A public reprimand; Restriction or limitation of the person's license (e.g., limiting one or more specified nursing activities); Suspension of the license; Revocation of the license; Assessment of a fine; Submit to care, counseling or treatment designated by the Board; Participate in a program of education or counseling, including remedial education; Practice for a specified period of time under the direction of an RN or VN designated by the Board; Perform public service the Board considers appropriate; Abstain from the consumption of alcohol or the use of drugs and submit to random periodic drug screens; Accept a voluntary surrender of a license; Impose conditions for reinstatement of a license if the license has been revoked, suspended, or voluntarily surrendered; Place a probationary status on a license; Order a licensee to pay a refund to a consumer; Issue an emergency "cease and desist" order; and Enjoin a violation of the Nursing Practice Act or Board rule Cases that result in disciplinary action become public information
Role of LVN
Directed scope of practice that must be supervised Educated to care for clients with stable and predictable conditions Educated to do hands-on assessments using their senses
Factors Indicating Good Professional Character
Distinguish right from wrong; Think and act rationally; Keep promises and honor obligations; Accountable for own behavior; Able to practice nursing in an autonomous role with patients/clients, their families, significant others, and members of the public who are or who may become physically, emotionally, or financially vulnerable; Recognize and honor the interpersonal boundaries appropriate to any therapeutic relationship or health care setting; and Promptly and fully self-disclose facts, circumstances, events, errors, and omissions when such disclosure could enhance the health status of patients/clients or the public or could protect patients/clients or the public from unnecessary risk of harm [ Rule 213.27(b)(2)(A-G)]. Any conviction for a felony or for a misdemeanor involving moral turpitude or order of probation with or without an adjudication of guilt for an offense that would be a felony or misdemeanor involving moral turpitude if guilt were adjudicated [Rule 213.27 (b)(3)]. Any revocation, suspension, or denial of, or any other adverse action relating to, the person's license or privilege to practice nursing in another jurisdiction [Rule 213.27 (b)(4)].
Elements of a Nursing Malpractice Lawsuit
Duty - the existence of a duty, owed by the nurse to a patient, to conform to a recognized standard of care Breach - a failure to conform to the required standard of care Harm - an actual injury Cause - there must be proof that the injury was caused by the nurse's act or omission
Licensure Verification
Employers may verify the licensure status of all nurses seeking employment online or by phone.
Employer Disciplinary Action
Employment and licensure issues are separate. An employer may take disciplinary action before review by the peer review committee is conducted, as peer review cannot determine issues related to employment. The role of incident-based peer review is to determine if licensure violations have occurred and, if so, if the violations require reporting to the board.
The Texas Board of Nursing (BON)
Established by passage of the NPA BON empowered by NPA with the responsibility and legal authority for ensuring competent practitioners of nursing. Grants authority to the BON to make the rules and regulations to carry out the act.
Duty of a Nurse in any Practice Setting
Establishes, through the NPA and Board Rules, that a nurse has a responsibility and duty to a client/patient to provide and coordinate the delivery of safe, effective nursing care. This duty supersedes any facility policy or physician order. Duty to the patient Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App.--Austin, 1983) The court in affirming the disciplinary action of the Board, held that a nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order. This landmark case involved a gentleman who arrived to a rural hospital via private vehicle. The gentleman was experiencing severe chest pain, nausea, and sweating—all hallmark symptoms of myocardial infarction (heart attack). Nurse Lunsford was summoned to the ER waiting room by this gentleman's friend. Upon seeing the acute distress the man was experiencing and hearing his symptoms, she instructed his friend to drive the man to the nearest facility equipped to handle heart attack victims. This facility was 24 miles away. The man succumbed to the heart attack 5 miles away from the small hospital. When the Board sought to sanction the nurse's license, the nurse maintained that the ER physician (who never saw the man) told her the man needed to be transported to the larger facility. The facility policy was also to transfer patients experiencing heart attacks (via ambulance) to the larger facility that was equipped to provide the broad range of therapies that might be needed. The court sided with the BON and agreed that the nurse had the knowledge, skills and abilities to recognize the life-threatening nature of the man's symptoms. Because of this knowledge, the court maintained that it was the nurse's duty to act in the best interest of the client by assessing the man, taking measures to stabilize him and to prevent complications, and communicating his condition to other staff (such as the MD) in order to enlist appropriate medical care
Intentional Tort: Assault
Example of this tort: A nurse threatens to place an NG tube in a client who is refusing to eat Intentionally placing another in apprehension or fear that they will suffer harmful or offensive contact.
Criminal Law
Federal or state government attempting to deprive an individual of life or liberty for something the law considers an offence against society in general
Nursing Tasks Prohibited from Delegation
Formulation of the nursing care plan and evaluation of the client's response to the care rendered. Specific tasks involved in the implementation of the care plan which require professional nursing judgment or intervention. The responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client's significant others in accomplishing health goals. Administration of medications, including intravenous fluids, except by medication aides as permitted under §224.9 of this title (relating to The Medication Aide Permit Holder).
Safe Harbor
Idea is that patients are better off with the nurse than without the nurse in the vast majority of cases.a nurse may engage in an assignment or requested conduct unless the requested assignment or conduct is one that: - constitutes a criminal act -constitutes unprofessional conduct, or -the nurse lacks the basic knowledge, skills, and abilities necessary to deliver nursing care that is safe and that meets the minimum standards of care to such an extent that accepting the assignment would expose one or more patients to an unjustifiable risk of harm
Employer Duty to Report
If an employer terminates a nurse (voluntarily or involuntarily), suspends for seven (7) or more days, or takes other substantive disciplinary action against a nurse or substantially equivalent action against an agency nurse for nursing practice errors/concerns, the employer must report to the Board (BON) in writing [NPA § 301.405 (b)]
Incident-Based Peer Review
Incident-Based, because it relates to an incident reported after the fact, so it starts with an error or incident Initiated by a nurse, facility, association, school, agency, or any other setting that utilizes the services of nurses
Alternative to Mandatory Reporting
Instead of reporting to the board under a nurse may make a report to: 1. a nursing peer review committee under Chapter 303; or 2. to the nursing educational program in which the student is enrolled.
Good Professional Character
Integrated pattern of personal, academic and occupational behaviors which, in the judgment of the Board, indicates that an individual is able to consistently conform his or her conduct to the requirements of the Nursing Practice Act, the Board's rules and regulations, and generally accepted standards of nursing practice including, but not limited to, behaviors indicating honesty, accountability, trustworthiness, reliability, and integrity [TAC § 213.27(a)].
Intentional Tort: Battery
Intentional contact that is harmful or offensive, or creating the apprehension that such contact is imminent. -false imprisonment accompanied by forceful restraint or threat of restraint is BATTERY. IE: Restraining a person to give an injection against their consent or order
Standards of Nursing Practice (cont)
Know and conform to the Texas Nursing Practice Act and the board's rules and regulations Promote a safe environment for clients and others Know the rationale for and the effects of medications and treatments and correctly administer Accurately and completely report and document Respect the client's right to privacy by protecting confidential information Promote and participate in education and counseling Notify the appropriate supervisor when leaving a nursing assignment Know, recognize, and maintain professional boundaries of the nurse-client relationship
Rule 217.11. Standards of Nursing Practice
Know, recognize, and maintain professional boundaries of the nurse-client relationship
BON Responsibilities & Services
Licensing qualified practitioners Enforcement - investigating violations of the NPA and initiating appropriate legal action when necessary Establishing minimum standards for educational programs in nursing
Nurse Licensure Compact - Requirements
Maintain home state license Adhere to state practice laws of state in which patient is located at the time care is provided Use multistate privilege only in party states Hold home state license in only one party state at a time.
Safe Harbor Peer Review
May be initiated by a LVN, RN or APRN prior to accepting an assignment or engaging in requested conduct that the nurse believes would place patients at risk of harm, thus potentially causing the nurse to violate his/her duty to the patient(s). Invoking safe harbor in accordance with Rule 217.20 protects the nurse from licensure action by the BON as well as from retaliatory action by the employer. Employers of 10 or more licensed nurses must have a Peer Review Committee [TOC § 303.0015 (a) (1) and (2)]. The committee shall give the nurse being reviewed at least minimum due process [TOC § 303.002 (e)]. Safe Harbor must be invoked prior to engaging in the conduct or assignment for which peer review is requested, and may be invoked at any time during the work period when the initial assignment changes. Examples of Safe Harbor situations include clinical assignments related to staffing and/or acuity of patients where the nurse believes patient harm may result [TAC § 217.11(1)(B) and (T)]. Safe Harbor allows nurses to accept assignments, and do the best patient care they are capable of, without fear of licensure action by the Board if they accidentally commit an error. It is important to remember; however, that NPA § 301.352 gives a nurse the right to refuse to engage in conduct related to patient care if they believe the conduct would violate the NPA or any BON rule
Rule 217.12. Unprofessional Conduct
Misconduct — actions or conduct that include, but are not limited to: (D) Violating professional boundaries of the nurse/client relationship including but not limited to physical, sexual, emotional or financial exploitation of the client or the client's significant other(s)
BON & Complaints
More than 16,000 complaints per year are typically received by the BON. Not all complaints result in an investigation or disciplinary action by the Board. In all cases, the identity of the complainant is kept confidential. The nurse is notified of the investigation and invited to respond. The investigator gathers and reviews evidence, and then reviews the nurse's response. Then, a decision is made by the Board.
Use of Titles
Must hold a license to use the title:Registered Nurse or RN Professional Nurse Licensed Vocational Nurse or LVN Any designation that implies that the person is a licensed registered or vocational nurse
Malpractice
Negligence committed by a person in his or her professional capacity is malpractice. Also known as professional negligence. Medical and nursing malpractice occur when a doctor or nurse fails to do that which a reasonable, prudent doctor or nurse would do under the same or similar circumstances, or does that which a reasonable or prudent doctor or nurse would not do under the same or similar circumstances.
Minimum Due Process Rights Include
Notice must be provided in writing in person or by certified mail Notice must Include a description of the event(s) to be evaluated in sufficient detail to inform the nurse of the incident, circumstances and conduct (error or omission) The nurse must have the opportunity to: (i) submit a written statement regarding the event under review; (ii) call witnesses, question witnesses, and be present when testimony or evidence is being presented
Activation of Safe Harbor Peer Review
Notify the supervisor making the assignment in writing that the nurse is invoking Safe Harbor. This must be done prior to engaging in the conduct or assignment for which safe harbor is requested. The "Comprehensive Request for Safe Harbor Nursing Peer Review" must be completed by the end of the work period and before leaving the practice setting. Please DO NOT mail or fax your request for Safe Harbor Nursing Peer Review to the Board of Nursing. The BON cannot conduct Peer Review - this must be done through the facility or agency where the assignment was made to you.
Nurse Licensure Compact - Definitions
Party states - states who have adopted the compact Home state license - where you permanently reside Remote state - where you practice using multistate privilege (must be a party state)
Practice in a Non-Party State
To practice in a state that is not part of the Compact, the nurse must obtain license from the non-party state May concurrently hold a home state license and a license to practice in a non-party state If you live in a non-party state, you must obtain a non-resident Texas license in order to practice in Texas
Nurse Practice Act (NPA)
defines the scope and limitations of professional nursing practice; vary from state to state. The practice of nursing is a right granted by a state to protect those who need nursing care. The guidelines of the NPA and its rules provide safe parameters within which to work, as well as protect patients from unprofessional and unsafe nursing practice. The act is a dynamic document that evolves and is updated or amended as changes in scope of practice occur.All states and territories have enacted a NPAGenerally, NPAs include:Authority, power and composition of a board of nursingEducation program standardsStandards and scope of nursing practiceTypes of titles and licensesRequirements for licensureGrounds for disciplinary action, other violations and possible remedies
Jurisprudence
the science or philosophy of law
Role of RN
"The RN provides a unique, comprehensive assessment of the health status of the client, applying principles of ethics, client safety, health promotion and the nursing process. The nurse then develops and implements an explicit plan of care." (NCLEX-RN, 2013, p. 4) Works in both structured and unstructured healthcare environments Responsible for well-being of all patients Functions within the scope of the NPA and Board rules
Intentional Tort: False Imprisonment
"unjustifiable detention of a person without legal warrant to confine the person" (client has the right to leave AMA) -false imprisonment accompanied by forceful restraint or threat of restraint is BATTERY.
Laws & Regulations Regarding Nursing
- Texas Nurse Practice Act (NPA) - Texas Board of Nursing (BON) Rules & Regulations - BON Position Statements Don't have the force of law, but the Board strongly encourages nurses to choose those position statements applicable to their practice setting and incorporate them into their daily practice to assure patient safety
Renewal of Licensure
60 days prior to license expiration, the BON will mail a postcard reminder to renew online. This is one of the reasons it is important to keep your contact information up to date!
Quasi-Intentional Tort: Defamation
A communication that tends to hold the plaintiff up to hatred, contempt or ridicule, or to cause him to be shunned or avoided. Tarnishing the reputation of someone.
Due Process Rights
A facility conducting incident based peer review shall: Have written policies and procedures about peer review Nurse must receive notice regarding the review, and have an opportunity to respond to the notice Nurse may have an attorney, will get feedback after the decision, and have a chance to respond to the decision
Mandatory Reporting Requirement
A nurse shall report to the board if the nurse has reasonable cause to suspect that: 1. Another nurse has engaged in conduct subject to reporting; or 2. the ability of a nursing student to perform the services of the nursing profession would be, or would reasonably be expected to be, impaired by chemical dependency.
Protections for the Nurse
A nurse who in good faith requests Safe Harbor peer review: 1. may not be disciplined or discriminated against for making the request; 2. may engage in the requested conduct pending the peer review; and 3. may not be disciplined by the board for engaging in that conduct while the peer review is pending.
Licensure Required
A person may not practice or offer to practice professional nursing or vocational nursing in this state unless the person is licensed [NPA § 301.251] This section of the NPA establishes the NPA as a practice control act for RNs and LVNs
IT IS A NURSE'S RESPONSIBILITY TO KNOW NPA/RULES AND REGULATIONS
As a nurse in Texas, you have a responsibility to know and follow the Nursing Practice Act and all applicable BON Rules and Regulations relating to your nursing practice. All current BON Rules and Regulations and the Nursing Practice Act can be downloaded from the BON's web site at www.bon.texas.gov
Delegation
Authorizing an unlicensed person to provide nursing services while retaining accountability for how the unlicensed person performs the task. It does not include situations in which an unlicensed person is directly assisting a RN by carrying out nursing tasks in the presence of a RN [Rule 224.4 (3)]. RNs may delegate: LVNs may supervise The RN is responsible for the evaluation of the delegated task to ensure it was completed and completed correctly [Rule 224.3].According to the BON website, many find delegation to be a perplexing concept with multiple nuances. The BON created the Delegation Resource Packet to afford RNs clearer direction for delegation in a variety of settings thereby improving the delegation process
Minor Incident Exclusions
Conduct that cannot be considered a minor incident: 1. Any error that contributed to a patient's death; 2. Criminal conduct defined in NPA § 301.4535; or 3. A serious violation of the board's Unprofessional Conduct Rule 217.12 involving intentional or unethical conduct such as fraud, theft, patient abuse or patient exploitation.
Withdrawal of Request for Safe Harbor
The nurse's request for Safe Harbor Peer Review does not become invalid and the nurse does not have to withdraw his/her request for Safe Harbor just because a supervisor is able to respond with adequate staff, equipment, or whatever else was at issue with the original requested assignment. It is the nurse's choice whether or not he/she wishes to still have a nursing peer review of the situation.
Vocational Nursing
Practice in Planning of Nursing Care Assisting in evaluating patient response to nursing care Perform focused assessment
Professional Nursing Only
Practice independently within NPA and board rules Make nursing diagnosis Develop a nursing care plan Perform comprehensive assessment Evaluate patient response to nursing care
The Board:
Protects the public from unsafe nursing practice, provides approval for more than 200 nursing education programs, issues licenses to more than 27,000 nurses per year by examination to new graduates and by endorsement to licensees from other states seeking a Texas license, as well as providing nursing practice and education guidance to more than 350,000 currently licensed nurses practicing in the State of Texas.
Continuing Competency (TAC Chapter 216)
Purpose: to ensure nurses stay abreast of current industry practices, enhance their professional competence, learn about new technology and treatment regimens, and update their clinical skills. [TAC § 216.2] All nurses are required to demonstrate continuing competency for renewal of licensure. Methods: Complete 20 hours of continuing education, or Attain, maintain, or renew an approved national nursing certification in the area of practice Nursing Jurisprudence & Ethics - 2 hours [Rule 216.3 (g)] Older Adult or Geriatric Care - 2 hours [Rule 216.3 (h)]
Criteria for Delegation
RNs may delegate LVNs may supervise The RN is responsible for the evaluation of the delegated task to ensure it was completed and completed correctly [Rule 224.3].
Criminal Behavior Disclosure
Requirement for criminal history for applicants for a license [NPA § 301.2511]. Requirement for criminal history for renewal of license [NPA § 301.3011]. Disclose: Convictions Deferred adjudications Probated sentences Domestic offenses
Responsibilities During Investigation
Respond promptly to all requests for information by the investigator assigned to your case. Ask your investigator questions so you are certain you understand what is happening Keep the investigator informed about how, when, and where you can be reached, and supply a phone number Respond promptly to the notice letter informing you of the allegations against you The response should be concise, clearly written, and should address the facts as you know them
LVN Supervision
The practice of vocational nursing must be performed under the supervision of a registered nurse, physician, physician assistant, podiatrist, or dentist.
Civil Law
Seeks to resolve disputes between private parties, which often result in payment of money
Nurses transitioning back to practice or to new primary practice area
Should not act as charge nurse for at least six months, unless a lesser time period is agreed upon by the nurse and his/her supervisor, based on the competency of the nurse
Standards of Nursing Practice
Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing license or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted.
BON Mission Fulfilled Through
The regulation of the practice of nursing The approval of nursing education programs.
Unprofessional Conduct
The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established.
Rule 217.12. Standards of Nursing Practice
This rule covers standards of nursing practice that apply to all nurses, including RNs, LVNs, and APRNs. This is one rule to know well!
Graduate Nurse
Supervision for a period of six months, or lesser time, if agreed upon by the newly licensed nurse and the supervising nurse Competence to perform independently should be mutually determined by the new graduate and the supervising nurse and demonstrated and supported by documentation
No More Paper Licenses
The BON discontinued issuing wallet-sized paper licenses for nurses renewing their licenses beginning September 1, 2008Paper license certificates are issued for: Graduate nurses who pass the NCLEX® exam and obtain their initial license in Texas;Nurses who hold licenses in other states and are obtaining a Texas license for the first time; andNurses who receive full licensure as APRNs
Rules & Regulations
The NPA itself is insufficient to provide the necessary guidance for the nursing profession, therefore, each NPA establishes a board of nursing (BON) that has the authority to develop administrative rules or regulations to clarify or make the law more specific. Rules and regulations must be consistent with the NPA and cannot go beyond it. These rules and regulations undergo a process of public review before enactment. Once enacted, rules and regulations have the full force and effect of law.
Professional Boundaries
The appropriate limits which should be established by the nurse in the nurse/client relationship due to the nurse's power and the patient's vulnerability. Refers to the provision of nursing services within the limits of the nurse/client relationship which promote the client's dignity, independence and best interests and refrain from inappropriate involvement in the client's personal relationships and/or the obtainment of the nurse's personal gain at the client's expense. A zone of patient-centered care is in the center of the professional behavior continuum. This is where the patient interactions should occur for effectiveness and patient safety. Over-involvement with a patient is on the right side of the continuum; this includes boundary crossings, boundary violations and professional sexual misconduct. Under-involvement lies on the left side; this includes distancing, disinterest and neglect, and can be detrimental to the patient and the nurse.
Six Step Decision Making Model
Tool developed by the BON to assist nurses in making good professional judgments about the nursing tasks or procedures they choose to undertake. Goal is making sure that he/she only accepts those assignments for which the nurse has the education, training, and skill competency 1. Is the activity consistent with the Nursing Practice Act (NPA), Board Rules, and Board Position Statements and or/Guideline? Yes: continue. No: stop. 2. Is the activity appropriately authorized by valid order/protocol and in accordance with established policies and behaviors? Yes: continue. No: stop. 3. Is the act supported by either research reported in nursing and health-related literature or in scope of practice statements by national nursing organizations? Yes: continue. No: stop. 4. Do you possess the required knowledge and have you demonstrated the competency required to carry out this activity safely? "" 5. Would a reasonable and prudent nurse perform this activity in this setting? 6. Are you prepared to assume accountability for the provision of safe care and the outcome of the care rendered? Yes: Perform the activity. No: stop.
Quasi-Intentional Tort: Defamation Types
Types: Libel - printed or broadcast Slander - spoken
Unprofessional conduct
Using fraud or deceit in procuring a license Improperly using a nursing license Impersonating another person in examination Aiding and abetting someone in unlawful practice Failing to cooperate with a lawful investigation Behaving in a threatening or violent manner in the workplace Offering, giving, soliciting, or receiving or agreeing to receive, directly or indirectly, any fee or other consideration to or from a third party for the referral of a client in connection with the performance of professional services.
Clearly Legible Insignia
When interacting with the public in a nursing role, RNs and LVNs must wear an insignia identifying them as RNs or LVNs [NPA § 301.351] APRNs practicing in an advance practice role must identify themselves with their APRN title BON Rule 217.10(b) requires the nurse's first or last name and licensure level
Ethical Conduct
Year after year, Nursing is recognized as one of the most trusted professions.It is important to maintain that trust, so we can practice efficiently....what is good and bad and with moral duty and obligation...
Minor Incidents
conduct that does not indicate that the continuing practice of nursing by an affected nurse poses a risk of harm to the client or other person
Nurse Licensure Compact (NLC)
endorsed by the National Council of State Boards of Nursing (NCSBN) as a framework for regulating the interstate practice of nursing for RNs and LPNs/VNs; under this concept, nurses holding a valid license in one state could practice (both physically in person and electronically by using the telephone or telemedicine connectivity to assess and provide care) in other states, according to the rules and regulations of the states The Nurse Licensure Compact (NLC) allows RNs and LVNs to have one multistate license, with the ability to practice in both their home state and other NLC states.The APRN Compact allows an advanced practice registered nurse to hold one multistate license with a privilege to practice in other compact states.Agreement among states to mutually recognize each others' licenses Texas among first to adopt Premise: current licensure requirements essentially the same from state to state Does not interfere with each state defining scope of practice Only defines requirements to hold license
