3. Broadening Scope of Practice
• Refers to permissible boundaries of practice for
health care professionals, defined in state statutes,
which define the actions, duties, & limits of nurses in
their particular roles.
• Role of nurse continues to expand due to
– shortage of primary care physicians
– ever-increasing specialization
– improved technology
– public demand
– expectations within the profession itself.
3
4. Nursing Practice - I
1901 – NY begins to organize passage of nurse practice
legislation
1903 – NC, 1st nurse registration act
1905 – Columbia U., Certification for nurse leaders
1937 – ANA recommendsuse their professional org. to
improve working conditions
4
5. Nursing Practice - II
1938 – NY requires mandatory licensure
1946 – ANA Convention calls for higher wages
1952 – All states enacted nurse practice acts
1955 – ANA approves model definition for nursing
1957 – California: Nurses supported to perform venous
punctures
5
6. Nursing Practice - III
1966 – Michigan: Use of defibrillators by nurses
1968 – Hawaii: Nurses perform cardio-pulmonary
resuscitation
1970 – ANA: Nursing practice to include “nursing
diagnosis”
1971 – Idaho: Scope of practice for NPs includes
Diagnosis & treatment
6
7. Nursing Practice - IV
1972 – New York: Expanded Nurse Practice Act,
Broader definition of nursing
1973 – ANA: 1st Guidelines for geriatric NPs
1975 – Missouri: Nursing diagnosis scope expands
1980 – ANA publishes model NP act for state
legislators to provide consistency for state nurse
practice acts
7
8. Nursing Practice - V
1985 – New York: Nurses provide primary
health care services
1989 – New York: NPs diagnose, treat, write
prescriptions
1990 – ANA amends model definition of nursing
to include advanced NPs
8
9. Nursing Diagnosis – I
• Defendant physicians ignored nurse's assessment of
patient's diagnosis, which contributed to delay in
treatment & injury to the patient. Nurse testified that
she told the physician that patient's signs & symptoms
were not those associated with indigestion. Defendant
physician objected to this testimony, indicating that
such a statement constituted a medical diagnosis by a
nurse. The trial court permitted the testimony to be
entered into evidence.
What do you think happened on appeal?
9
10. Nursing Diagnosis – II
Missouri Court of Appeals affirmed lower court's
ruling, holding that evidence of negligence
presented by a hospital employee, for which an
obstetrician was not responsible, was
admissible to show events that occurred during
patient's hospital stay.
– See text case: Cignetti v. Camel
10
11. Nurse Licensure I
Requirements for Licensure
– Reciprocity
• agreement between states whereby a nurse licensing
board in one state recognizes licensees of another
state.
– Endorsement
• boards determine whether out-of-state nurses'
qualifications are equivalent to their own state
requirements at the time of initial licensure.
11
12. Nurse Licensure II
Requirements for Licensure cont.
– Waiver
• When applicants do not meet all the requirements for
licensure but have equivalent qualifications, the
specific prerequisites of education, experience, or
examination may be waived.
– Examination
• Some states will not recognize out-of state licensed
nurses & make it mandatory that all applicants pass a
licensing examination.
13. Suspension & Revocation
• Violations may include
– procurement of a license by fraud
– unprofessional, dishonorable, immoral, or illegal
conduct
– performance of specific actions prohibited by
statute
– malpractice.
13
14. Practicing without a License
• Health care orgs are required to verify each
nurse's license is current.
• Mere fact that an unlicensed practitioner is
hired will not generally in & of itself impose
additional liability unless a patient suffered
harm as a result of an unlicensed nurse's
negligence.
14
15. American Nurses Association
• National professional organization of graduate RNs.
• Membership is available to all graduate nurses who
are licensed in any jurisdiction of the United States.
• Purpose of the ANA is to
– foster high standards of nursing practice
– promote professional & educational advancement
of nurses & welfare of nurses to the end that all
people may have better nursing care.
15
16. National League for Nursing
Purpose to foster develop & improve hospital,
public health, & other organized nursing
services & nursing education through
coordinated action of nurses, allied
professional groups, citizens, agencies, &
schools.
16
18. Nurse Anesthetist - I
• Administration of anesthesia by a nurse anesthetist
requires special training and certification.
• Nurse-administered anesthesia was the first expanded
role for nurses requiring certification.
• Oversight & availability of an anesthesiologist are
required by most organizations.
18
19. Nurse Anesthetist - II
• Major risks for nurse anesthetists include
– improper placement of an airway
– failure to recognize significant changes in a
patient's condition
– improper use of anesthetics
• Nurse Anesthetist: Medical Supervision Require
19
20. Nurse Practitioner
• RNs who have completed the necessary education to
engage in primary health care decision making.
• Trained in delivery of primary health caare &
assessment of psychosocial & physical health
problems such as the performance of routine
examinations & ordering of routine diagnostic tests.
• NPs negligence imputed to physician
– See text case: Adams v. Krueger
20
21. Clinical Nurse Specialist – I
• Clinical nurse specialist is a professional RN with an
advanced academic degree, experience, and expertise
in a clinical specialty
(e.g., obstetrics, pediatrics, psychiatry).
• CNS acts as a resource for the management of
patients with complex needs and conditions.
• The CNS participates in staff development activities
related to his or her clinical specialty & makes
recommendations to establish standards of care for
those patients.
21
22. Clinical Nurse Specialist – II
• CNS functions as a change agent by
influencing attitudes, modifying behavior, &
introducing new approaches to nursing
practice.
• CNS collaborates with other members of the
health care team in developing and
implementing the therapeutic plan of care for
patients.ard of care
22
23. Nurse Midwife – I
• Nurse midwives provide comprehensive
prenatal care including delivery for patients
who are at low risk for complications.
• They often manage normal prenatal,
intrapartum, & postpartum care.
• Provided that there are no complications,
normal newborns are also cared for by a nurse
midwife.
23
24. Nurse Midwife – II
• Nurse midwives often provide primary care for
women's issues from puberty to postmenopaus
• Text Cases
– Practicing Without a License
– Standard of Care Required of a Nurse Midwife
24
25. Nurse Managers
• Chief nursing officer has responsibility for:
– maintaining standards of practice
– maintaining current p & ps
– recommending staffing levels
– coordinating & integrating nursing services with other
patient care services
– selecting nursing staff
– developing orientation and training programs.
• Failure to supervise
– can lead to disciplinary action
25
26. Special-Duty Nurse
• A health care professional employed by a
patient or patient's family to perform nursing
care for the patient
• If a master-servant relationship exists between
the org & special-duty nurse, doctrine of
respondeat superior may be applied to impose
liability on the org for nurse's negligent acts
26
27. Float Nurse
• Nurse who rotates from unit to unit based on staffing
needs
• “Floaters” can benefit an understaffed unit, but they
also may present a liability as well if they are
assigned to work in an area outside their expertise
• If a patient is injured because of a floater's
negligence, the standard of care required of the floater
will be that required of a nurse on the assigned patient
care unit
27
28. Nursing Assistant
• An aide who has been certified & trained to assist
patients with activities of daily living under the
direction & supervision of an RN or LPN
• Nursing assistants help with positioning, turning,
lifting & performing a variety of tests * treatments
• Failure to follow policy & safe practices
– patient scalded
– patient fall
– patient transfer
– Leaving Patient Unattended
28
29. Agency Staff
• Orgs are at risk for negligent conduct of
agency staff.
• Important that org be sure that agency workers
have necessary skills & competencies to carry
out duties & responsibilities assigned by org.
29
30. Student Nurses
• Student nurses are entrusted with the responsibility of
providing nursing care to patients.
• Students are personally liable for their own negligent
acts, & the facility is liable for their acts on basis of
respondeat superior.
• Student nurse are held to the standard of a competent
professional nurse when performing nursing duties
30
31. Medications Errors - I
• Failure to administer
• Failure to document wastage
• Administering unprescribed meds
• Administering wrong meds
• Failure to clarify orders
• Case: Negligent Drug Overdose
31
32. Medications Errors - II
• Administration of the wrong dosage
• Negligent drug overdose
• Administering by the Wrong Route
• Failure to Discontinue a Med
• Failure to Identify the Correct Patient
• Failure to Note an Order Change
32
33. Negligent Injection
• Nurse negligently injected the tetracycline into
or adjacent to the sciatic nerve, causing the
patient to permanently lose the normal use of
the right foot.
– ED
– Permanent injuries
– Negligent injection of Tetracycline
33
34. Failure to Follow
Physician’s Orders
• Nurses caused permanent drop foot to the
patient.
• They failed to follow the doctor’s verbal
orders to watch the patient closely & to place
him in one continuous passive motion machine
at a time during physical therapy.
34
35. Failure to Record Patient’s Care
Nurse admitted she failed to record site & mode of
injection in ED records. According to testimony of
two experts, failing to record this information is
below standard of care for nursing. Although these
omissions could not have affected administration of
the injection, they tend to indicate that in this instance
the nurse did not follow accepted procedure while
performing her job.
35
36. Failure to identify Correct Patient
• Surgical staples removed-wrong patient
Meena v. Wilburn
– Chart was not checked
– Wrist band was not checked
– Wrist band was not checked against chart
36
37. BURNS
Negligent use of a Bovie plate led to liability in
Monk v. Doctors Hospital, in which a nurse had
been instructed by the physician to set up a Bovie
machine. The nurse placed the contact plate of the
Bovie machine under the patient's right calf in a
negligent manner and the patient suffered burns.
The patient introduced instruction manuals, issued
by the manufacturer, supporting a claim that the
plate was placed improperly placed. These
manuals had been available to the hospital.
37
38. Infections
• Cross Contamination
• Failure to Notify Physician
• Failure to follow established procedures
– Infection control
– Sterile technique
– Decubitus ulcers
38
39. Inappropriate Care – I
• Plastic cup as arm guard?
– Morris alleged from personal observation that the
laceration to her daughter's arm was caused by the
jagged edges of a plastic cup that had been split &
placed on her arm to guard an IV site.
• Text case: Morris v. Children’s Hospital
Medical Ctr.
• Was this a breach of the standard of care for
nurses?
39
40. Inappropriate Care – II
A nurse, in her affidavit, who stated her
qualifications as an expert, expressed her
opinion that the practice of placing a split
plastic cup over an IV site as a guard
constituted a breach of the standard of nursing
care.
40
41. Delay in Treatment
• When minutes count!
• Nurses Delay contacting obstetrician
– Text Case: Howerton v. Mary Immaculate
– Patient suffers
– At trial, expert witness opined that labor &
delivery room nurses should have immediately
gone to the patient when they were notified of
worsening pain, evaluate her condition, & notify
her physician.
41
42. Leaving Patients Unattended
• Navy Veteran Left Unattended
– Suffered anoxic brain injury following a
complication with his endotracheal tube
– Left permanently disabled
– Court awarded $3,500,000
42
43. Failure to Follow Instructions
• Failure of a nurse to follow the instructions of a supervising
nurse to wait for her assistance before performing a
procedure can result in revocation of the nurse's license.
• Heart monitor was connected incorrectly & resulted in an
electrical shock to the infant.
• Dangers of electric cords are within the realm of common
knowledge.
• Record showed the nurse failed to exercise ordinary care in
connecting the infant.
– Text Case: Cafiero v. North Carolina Board of Nursing
43
44. DILEMMA OF TWO STANDARDS
When faced with dilemma of 2 standards for rendering
patient care, an org may find it more attractive to
adopt the 1 least restrictive or labor intensive. This
could prove to be a costly decision for both patient &
org by increasing
– the risk of patient injury
– organization's exposure to corporate liability for
any injury suffered from following the less
restrictive standard.
• See text case: Edwards v. Brandywine Hosp.
44
45. Failure to Monitor Vital Signs
• Evidence presented indicated that the standard of care
would require that fetal heartbeats be monitored every
10 minutes following removal of the fetal monitor.
The evidence presented indicated that this did not
occur.
– See text case: McCann v. ABC Insurance Co.
• Failure to Repeat Vital Signs
– Porter v. Lima Mem’l Hosp.
45
46. Failure to Report:
Physician’s Negligence
• Note changes in patient’s condition
• Report changes in patient’s condition
– Prompt notification required
– Physician failure to respond
– Need to report “all” patient symptoms
46
47. Failure to Question Discharge
• Premature Discharge
– A nurse has a duty to question the discharge of a
patient if he or she has reason to believe that such
discharge could be injurious to the health of the
patient.
• See text case: Koeniguer v. Eckrich
47
48. Failure to Question Discharge Swollen
Beyond Recognition
• The hospital's negligence is based on acts of
omission, by failing to have the patient examined by a
physician and by discharging her in pain.
• The evidence presented a woman conscious of her
last days on earth, swollen beyond recognition, tubes
exiting almost every orifice of her body, in severe
pain, and who deteriorated to the point where she
could not verbally communicate with loved ones.
– See text case: NKC Hosps., Inc. v. Anthony
48
49. Failure to Note Changes in Patient’s
Condition – I
• Nurses have responsibility to observe the
condition of patients under their care & report
any pertinent findings to the attending
physician.
• Failure to note changes in a patient's condition
can lead to liability on the part of the nurse &
organization.
49
50. Failure to Note Changes in Patient’s
Condition – II
Nurse assigned to monitor a postsurgical patient,
left the patient, & failed to recognize the
patient stopped breathing. The nurse had been
assigned to monitor the patient in the recovery
room. She delegated that duty to another nurse
& failed to verify the nurse accepted the
responsibility.
– See text case: Eyoma v. Falco
50
51. Prompt Notification Required
• Physician inserted a catheter into the wrong artery in
the patient’s right leg. This compromised the blood
flow to the leg, causing loss of pulse & sensation.
• This error was compounded when hospital nurses on
the patient's floor were unable to reach the physician
for 6 hours & never attempted to reach a backup
physician, to alert them of the patient’s deteriorating
condition.
– See text case: Cuervo v. Mercy Hospital, Inc.
51
52. Failure to Report
Deteriorating Condition
An organization's policies & procedures should
prescribe guidelines for staff members to follow
when confronted with a physician or other health care
professional whose action or inaction jeopardizes the
well-being of a patient.
– See text case: Goff v. Doctors General Hospital
52
53. Timely Reporting of
Patient Symptoms
Court held that there was sufficient evidence to
authorize the jury to find that the nurse was
negligent in failing to timely notify the
physician that delivery of plaintiff's child was
imminent. This delay resulted in an unattended
childbirth with consequent injuries. The trial
court had awarded the plaintiff $15,000.
53
54. Failure to Report
Patient Symptoms
Hospital's nurse was negligent in failing to inform the
physician of all the patient's symptoms, to conduct a
proper examination of the plaintiff, & to follow the
directions of the physician.
– See text case: Citizens Hospital Association v.
Schoulin
54
55. Failure to Report
Defective Equipment
• Failure to report defective equipment can
cause a nurse to be held liable for negligence if
the failure to report is the proximate cause of a
patient's injuries.
• The defect must be known & not hidden from
sight.
55
56. Incorrectly Transcribing
Telephone Orders
• Periodic contradictions between what physicians claim
they ordered & what nurses allege they ordered.
• Orders should be read back for verification purposes.
• Questionable orders must be verified with prescribing
physician.
• Physicians must authenticate their verbal order(s) by
signing the written order in the medical record.
• Nurses who disagree with a physician's order should not
carry out an obviously erroneous order.
• Report to the supervisor concerns with a particular order.
56
57. Misidentifying Infants
• Inadvertent or negligent switching of infants can lead
to liability for damages. Damages in the amount of
$110,000 were awarded for the inadvertent switching
of two babies born at the same time in De Leon Lopez
v. Corporacion Insular de Seguros.
• Follow org p & p in patient identification process.
• Always verify infant’s identification badge with
mother’s.
57
58. Patient Falls &
Restraints
• Among senior citizens, falls represent the fifth
leading cause of death, and the mortality rate
from falls increases significantly with age.
• Text cases
– Failure to Follow Policy
– Failure to Raise Bedrails
– Nurse Followed Safe Procedures
– Fall from Examination Table
58
59. Negligent Care - I
Brandon v. HMA, Inc. v. Bradshaw
• Failure to
– properly monitor patient
– report vital information to patient
• Allowed condition to deteriorate
– to critical stage
– before implementing urgent care
– Implementing life support
59
60. Foreign Objects:
Left in Patients
• Surgical Instrument Left in Patient
– See text case: Ross v. Chatam
• Sponge & Instrument Miscount
– See text case: Romero v. Bellina
– Whose responsibility? Discuss.
– Nurses & Surgeons Responsible?
60
61. Improper Sterilization
• The patient in Howard v. Alexandria Hosp. brought a
medical malpractice action against the hospital,
seeking damages arising out of an operation
performed with unsterile instruments.
• Nurse in charge of the autoclave used to sterilize
instruments was alleged not to have properly
monitored the sterilization process.
– See text case: Howard v. Alexandria Hosp.
61
62. Negligent Procedure
Cutting IV Tube – I
• A nurse employed by the defendant amputated nearly
one third of a one-month-old infant’s index finger while
cutting an IV tube.
• $87,000 for past pain & suffering & $50,000 for future
damages.
• Defendant moved to set aside the verdict & sought a new
trial.
– What do you think the final outcome of this case was?
• See text case: Ahmed v. Children's Hospital of
Buffalo
62
63. Negligent Procedure
Cutting IV Tube – II
The appellate court found that the jury's award of
damages did not deviate materially from what
would be reasonable compensation.
63
64. Monitor Alarm
Inappropriately Disconnected
• Monitor should have been on but was, however,
disconnected by the staff & caused patient’s death.
– See text Case: Odom v. State Department of
Health and Hospitals
64
65. REVIEW QUESTIONS - I
1. Describe how the scope of nursing is changing.
2. Describe how the roles of a nurse anesthetist, clinical
nurse specialist, nurse practitioner, and nurse midwife
differ.
3. Describe the various legal risk for nurses.
4. Describe the various medication errors that can occur
in the administration of medications.
65
66. REVIEW QUESTIONS - I
5. If a nurse disagrees with a physician's written orders,
discuss what action the nurse should take to protect
the patient’s safety.
6. Discuss why it is important to report significant
changes in a patient’s condition to the treating
physician.
7. If a nurse knows that a piece of equipment is
defective, should the nurse attempt to fix the
problem? Discuss your answer.
66
