NCLEX-RN: Management Principles and Legal Issues

Management Principles and Legal Issues: LEGAL ASPECTS OF NURSING

Focus topic: Management Principles and Legal Issues

Board of Registered Nursing (BRN)

Focus topic: Management Principles and Legal Issues

A. Each state has a Board of Registered Nursing (or its equivalent) organized within the executive branch of the state government. State boards of nursing are government agencies responsible for regulating nursing practice. The boards are charged with protecting the public by ensuring that standards of nursing practice are met and nurses are competent in their practice.

✦ B. Functions of each state’s Board of Registered Nursing.

  • Establishes and oversees educational standards.
  • Establishes professional standards (Table 2-1).
  • Monitors examinations for licensure (NCLEX®).
  • Registers and renews nurses’ licenses.
  • Conducts investigations of violations of the statutes and regulations.
  • Issues citations.
  • Holds disciplinary hearings for possible suspension or revocation of the license.
  • Imposes penalties following disciplinary hearings.
  • Establishes and oversees diversion programs in some states.

C. Typical powers and duties of a board of nursing include:

  • Interprets and enforces the state nurse practice act.
  • Administers nurse licensure by overseeing exams to grant licenses and taking action against licenses of nurses who have exhibited unsafe nursing practice.
  • Accredits or approves nurse education programs.
  • Develops nursing practice standards from the regulatory standpoint.
  • Develops policies, administrative rules, and regulations.

Management Principles and Legal Issues: STANDARDS OF CLINICAL NURSING PRACTICE

Focus topic: Management Principles and Legal Issues

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Management Principles and Legal Issues: Authorization to Practice Nursing

Focus topic: Management Principles and Legal Issues

A. To legally engage in the practice of nursing, an individual must hold an active license issued by the state in which he or she intends to work.
B. The licensing process.

  • The applicant must pass a licensing examination administered by the state Board of Registered Nursing, or the BRN may grant reciprocity to an applicant who holds a current license in another state.
  • The applicant for RN licensure examination must have attended a state accredited school of nursing, must be a qualified related nursing professional or paraprofessional, or must meet specified prerequisites if licensed in a foreign country.
  • Boards of Registered Nursing contract with the National Council of State Boards of Nursing, Inc., for use of the National Council Licensure Examination (abbreviated as NCLEX®).

Management Principles and Legal Issues: LEGAL ASPECTS OF MANAGEMENT

Focus topic: Management Principles and Legal Issues

Management Principles and Legal Issues: Nurse Practice Act

Focus topic: Management Principles and Legal Issues

✦ A. A series of statutes enacted by each state legislature to regulate the practice of nursing in that state.
✦B. Subjects covered by the Nurse Practice Act in each state include definition of scope of practice, education, licensure, grounds for disciplinary actions, and related topics.

  • Provides legal authority for nursing practice, including delegation of nursing tasks.
  • Many boards of nursing also provide decision trees or delegation checklists.

C. The Nurse Practice Acts are quite similar throughout the United States, but the professional nurse is held legally responsible for the specific requirements for licensure and regulations of practice as defined by the state in which he or she is working.
D. Responsibilities of the professional nurse involve a level of performance for a defined range of healthcare services.

  • Provide direct and indirect client care services.
  • Perform and deliver basic healthcare services.
  • Implement testing and prevention procedures.
  • Observe signs and symptoms of illness.
  • Administer treatments per physician’s order.
  • Observe treatment reactions and responses.
  • Administer medications per physician’s or licensed independent practitioner’s order.
  • Observe medication responses and any side effects.
  • Observe general physical and mental conditions of individual clients.
  • Provide client and family teaching.
  • Act as a client advocate when needed.
  • Document nursing care.
  • Supervise allied nursing personnel.
  • Collaborate with members of the healthcare team.

Management Principles and Legal Issues: Legal Issues

Focus topic: Management Principles and Legal Issues

A. Legal issues and regulations play a dominant role in nursing practice today.

  • The law provides a framework for establishing nursing actions in the care of clients.
  • Laws determine and set boundaries and maintain a standard of nursing practice.

✦B. The Nurse Practice Act defines professional nursing.

  • Recommends those actions that the nurse can take independently.
  • Recommends those actions that require a physician’s order before completion.

C. Each state has the authority to regulate as well as administrate healthcare professionals.

  • Provisions of Nurse Practice Acts are quite similar from state to state.
  • The nurse must know the licensing requirements and the grounds for license revocation defined by the state in which he or she works.

✦D. Legal and ethical standards for nurses are complicated by a myriad of federal and state statutes and the continually changing interpretation of them by the courts of law. Nurses today are faced with the threat of legal action based on negligence, malpractice, invasion of privacy, and other grounds.

Management Principles and Legal Issues: MANAGEMENT PRINCIPLES

Focus topic: Management Principles and Legal Issues

Management Principles and Legal Issues: RN Management Duties

Focus topic: Management Principles and Legal Issues

A. Responsibilities.
✦1. Performance, for compensation, of a defined range of healthcare services, including assessment, planning, implementation, and evaluation of nursing actions as well as teaching and counseling.
✦2. Administration of medications and treatments as prescribed by a licensed physician or other designated licensed professional.
✦3. Supervision of other nursing personnel; RN assigns, directs, monitors, and evaluates care performed by other personnel.

  • The RN delegates or assigns duties and tasks to LVN/LPNs, licensed caregivers.
  • The RN delegates or assigns tasks to unlicensed assistive personnel (UAPs) or certified nurse assistants (CNAs).
  • UAPs are individuals employed in healthcare settings to augment client care—persons without licensure under state Nurse Practice Acts.
  • CNAs have received minimal training (a few weeks) and have earned a certificate.

B. Requirements: specialized skills taught by and acquired at an accredited nursing school.
C. Standards of competent performance.

  • A registered nurse shall be considered competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological, and physical sciences in applying the nursing process.
  • Incompetence means lacking possession of or failure to exercise that degree of learning, skill, care, and experience ordinarily possessed and exercised by a competent registered nurse.

D. Professional functions of the RN (denoted by state).

  • Formulates a nursing diagnosis through observation of the client’s physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team.
  • Formulates a care plan, in collaboration with the client, which ensures that nursing care services provide for the client’s safety, comfort, hygiene, and protection, and for disease prevention and restorative measures.
  • Performs skills essential to the kind of nursing action to be taken, explains the health treatment to the client and family, and teaches the client and family how to care for the client’s health needs.
  • Delegates tasks to subordinates based on the legal scope of practice of the subordinate and on the preparation and capability needed in the tasks to be delegated, and effectively supervises nursing care being given by subordinates.
  • Evaluates the effectiveness of the care plan through observation of the client’s physical condition and behavior, signs and symptoms of illness, reactions to treatment, and through communication with the client and health team members, modifies the plan as needed.
  • Acts as the client’s advocate, as circumstances require, by initiating action to improve health care or change decisions or activities that are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided.

Management Principles and Legal Issues

Management Principles and Legal Issues: Management Decisions

Focus topic: Management Principles and Legal Issues

A. Understaffed units force RNs to prioritize and even ration their care giving.

  • Should the nurse give care to those who need it most?
  • Should the nurse care for those for whom she/ he can do the most good?

B. Any one of these options lessens the quality of care for the other clients.
C. Value of care extenders (UAPs, PCTs, and CNAs).

  • Alleviate or lessen nursing workload and stress.
  • Perform tasks that enable the professional staff to do more complex tasks.
  • Provide cost-effective quality client care.
  • Provide extra hands to get the work completed in a timely manner.

Management Principles and Legal Issues: Risk Management

Focus topic: Management Principles and Legal Issues

✦ A. Nurses are responsible to advise hospital authorities of unsafe nursing situations.
✦ B. Document unsafe staffing practices in an unusual occurrence and internal memo.

  • Provides legal protection.
  • These actions may be viewed as mitigating factor if you are sued.

✦ C. The ANA’s Code for Nurses states that the nurse is the client’s advocate and must take action if the rights or best interests of the client are in jeopardy.
D. ANA takes the position that nurses have a professional obligation to refuse assignments that put licenses or clients “in serious jeopardy.”

Management Principles and Legal Issues: DELEGATION PRINCIPLES

Focus topic: Management Principles and Legal Issues

Management Principles and Legal Issues: RN Delegation

Focus topic: Management Principles and Legal Issues

A. Delegation is a skill requiring clinical judgment and final accountability for client care. It is defined as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (Source: National Council of State Boards of Nursing).
B. State licensing laws designate that nurses are legally accountable for quality of care.
✦C. RNs are responsible for direct client care.

  • RNs decide which tasks to delegate and under what circumstances.
  • RNs must know what is safe delegation of nursing care tasks.
  • RNs must supervise (monitor and evaluate) outcomes for all delegated tasks.

✦D. RNs must know legal scope of practice of other licensed providers.
✦E. RNs must know competency of licensed and unlicensed personnel, as well as the tasks that may be delegated.

  • Some states identify tasks that may not ever be delegated (such as applying a sterile dressing by unlicensed personnel).
  • Review individual state rulings regarding tasks that may be legally delegated.
  • RNs may not delegate assessment, evaluation, or nursing judgment functions.

F. Tasks may be assigned to UAPs if the client is not medically fragile and/or performance of the task will not cause potential harm.
G. RNs and LVNs must check with their own states’ laws and regulations to determine which activities may not be performed by UAPs or CNAs. Examples of these tasks follow:

  • Administration of medications.
  • Venipuncture or intravenous therapy.
  • Parenteral or tube feedings.
  • Invasive procedures including inserting NG tubes, inserting catheters, or tracheal suctioning.
  • Assessment of the client’s condition.
  • Educating clients and their families concerning healthcare problems, including post-discharge care.
  • Moderate-complexity laboratory tests.

✦ RN Responsibilities That Cannot Be Delegated
A. Data entry into clients’ charts for all unlicensed personnel to whom tasks are delegated.
B. Initial health assessments (only by RN).
C. Care plan objectives—checked by RN if completed by LVN.

D. Review data obtained by other healthcare workers.
E. Complete referral form for additional client services.
F. Receive reports of client conditions and any unexpected findings from delegated activities.
G. Identify parameters for which worker is to notify nurse.
H. Carry out pain management activities (epidural narcotic analgesia done only by RN).
I. Check advance directives in client’s chart.
J. Organ donation—RN or LVN responsible for carrying out hospital policies.
K. Complete discharge teaching plan.

Management Principles and Legal Issues: Activity Delegation to the LVN/LPN

Focus topic: Management Principles and Legal Issues

✦A. Determine which tasks may be delegated.

  • Client diagnosis.
  • Legal limits of delegation to the LVN. (Does this state allow an LVN to administer IV drugs?)
  • Amount of judgment and experience needed to perform task or skill.
  • Predictability of outcome of task.
  • Whether assistant is capable of performing task.

B. Delegation and responsibility.
1. The RN is legally responsible for client care.

  • The LVN works with the RN, who initiates the nursing care plan; LVN may update care plan.
  • RN completes initial assessment; RN validates assessment changes noted by LVN.

✦2. RN initiates client teaching and evaluates the results.

  • LVNs may not initiate client teaching with exception of using standard care plan.
  • LVNs may reinforce client teaching.

3. Intravenous administration parameters vary by state.

  • RN may initiate IVs and add medications.
  • LVNs, depending on each state’s standards, may or may not add medications to an IV, do IV push, or administer piggyback solutions.
  • LVNs may add vitamins and minerals in most states.
  • LVNs may initiate IVs after completing IV course.

Delegation Policies and Regulations for Unlicensed Assistive Personnel and Certified Nurse Assistants

Focus topic: Management Principles and Legal Issues

A. The term UAP refers to healthcare workers who are not licensed to perform nursing tasks; this group also refers to those workers who are trained and certified, but not licensed.
B. Many boards of nursing have enacted laws to protect clients in acute care settings.
✦C. Basic principles of staffing should be based on several criteria:

  • Client care needs.
  • Severity of the client’s condition.
  • Services needed.
  • Complexity surrounding these conditions.

D. These policies further state that unlicensed personnel cannot be assigned in lieu of a registered nurse.

  • The nurse must determine which tasks may be performed by the UAP or CNA.
  • The nurse must assess real or potential harm to the client by assigning certain tasks to the UAP or CNA.
  • The nurse must “effectively supervise” other healthcare workers, taking into account:a. Client safety.
    b. Competency to perform task.
    c. Number and acuity of clients.
    d. Number and complexity of tasks.
    e. Staffing patterns.

✦E. Unlicensed personnel may not perform functions (even under the direct clinical supervision of an RN) that require a specific amount of scientific knowledge and technical skills.

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✦ Potential Problems in Delegation
A. Delegating too much responsibility.
B. Client welfare in jeopardy because of UAP and CNA activity.

  • Poorly supervised and monitored.
  • Unequipped to perform tasks.

C. CNAs and UAPs given responsibility beyond the legal limit specified.
D. Professional staff use UAPs in ways for which they are not prepared—also underutilizing these staff.
E. Inappropriate delegation leads to unsafe client situations.
F. Inability to recognize inappropriate delegation and unsafe client situations.
G. Signs that indicate the client’s condition is deteriorating are overlooked and the UAPs do not report it.

Appropriate Delegation to UAPs and CNAs

Focus topic: Management Principles and Legal Issues
✦A. Use of assistive personnel.

  • Evaluate specific client needs.
  • Judge assistant’s competence to perform assigned tasks.
  • Communicate expectations.
  • Provide instructions and active monitoring.
  • Monitor progress in client care through feedback, evaluate outcomes, and follow-up on identified problems.

✦B. Determining appropriate delegation to an unlicensed healthcare worker—ask these questions:

  • Can the UAP legally do this procedure according to the Nurse Practice Act in that state?
  • Has the UAP been trained to perform this procedure?
  • Can the UAP demonstrate this procedure safely and consistently?
  • Is the client status stable, and does this client require frequent assessment during the procedure?
  • Is the client response predictable?
  • When performing this task or activity, can the UAP or CNA obtain the same or similar results as the RN?
  • Can the UAP or CNA understand the rationale behind each task?

✦C. Parameters of delegation: Many state boards of nursing have identified the parameters of delegation. Examples of these “five rights of delegation”:
1. Right task—task that can be legally delegated to an LVN/LPN, CNA, PCT, or UAP. Check the state Nurse Practice Act to determine if the caregiver is trained to perform the task. Judge if the UAP or LVN is competent to perform the task. These include tasks that:

  • Frequently reoccur in the daily care of a client or group of clients.
  • Do not require the UAP to exercise nursing judgment that requires knowledge they do not have.
  • Do not require complex and/or multidimensional application of the nursing process.
  • The results are predictable and the potential risk is minimal.
  • Utilize a standard and unchanging procedure.

2. Right circumstance—the LVN, CNA, PCT, or UAP understands the elements of the procedure and the RN is assured that the UAP can perform the procedure safely in an appropriate setting. Caregiver is able to collect the right supplies to perform the procedure.

3. Right person—the right person (RN or LVN) delegates the right task (legally can be delegated to a CNA or UAP) to the right person (legally can perform the task) on the right client (stable with predictable outcomes).

4. Right communication—person delegating the task (RN or LVN) has described |the task clearly including directions, special steps of the task, and the expected outcomes.

5. Right supervisor—the RN or LVN delegating the activity answers the CNA’s or UAP’s questions and is available to problem solve if necessary (the task cannot be completed or the client’s condition changes). The CNA, PCT, or UAP performing the task reports its completion and the client response to the nurse who delegated the activity.

Modified from the National Council of State Boards of Nursing.

✦D. Duties commonly delegated to unlicensed assistive personnel.

  • Take vital signs.
  • Obtain height and weight.
  • Assist a client to bed.
  • Escort a client out of the hospital.
  • Bathe and make beds.
  • Daily care activities.
  • Personal hygiene activities.
  • Move and turn clients and reposition.
  • Transfer clients.
  • Assigned to clients requiring infection control precautions.
  • Record drainage from an NG tube.
  • Serve a food tray and feed a client.
  • Provide oral hygiene.
  • Obtain specimens that are nonsterile and noninvasive.
  • Monitor specific gravity.
  • Check urine glucose.
  • Administer disposable enema or tap water enema.
  • Apply elastic hosiery.
  • Perform range-of-motion exercises.
  • Initiate CPR or perform Heimlich maneuver (with CPR certification).
  • Work with a dying client.
  • Give postmortem care.
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