Lesson 1, Topic 1
In Progress

Regulation of Practice

July 10, 2022

Standards of care define acts whose performance is required, permitted, or prohibited. These standards of care derive from federal and state laws, rules, and regulations and codes that govern other professional agencies and organizations such as the American Nurses Association (ANA) and the Canadian Nurses Association (CNA). These organizations regularly evaluate existing standards and revise them as needed. Standards of care coupled with the scope of nursing practice give direction to the practicing nurse. They define the obligations of the nurse, including those activities that are obligation and those that are prohibited. Failure to adhere to these standards gives rise to legal liability. Ignorance of the requirements and limitations does not absolve liability.

Nursing liability falls into several areas: practice, monitoring, and communication. Box 2-4 shows common breaches of the standards of care. The legal test is the comparison with the hypothetical actions under similar circumstances of a reasonably prudent (careful, wise) nurse of similar education and experience. The standards of care follow those laws of the individual state. In reality, application of the standards is not always easy. Nursing shortages in some states have led to a need for individual nurses to take on increased responsibilities and work more hours. Personnel cutbacks often leave units short staffed, and nurses feel pressure to take on expanded duties; this raises their risk for liability considerably. In addition, special challenges face entry-level licensed nurses when they enter the workforce. Orientation programs often fail to adequately cover all the skills needed to be a competent practitioner. It is the nurse’s responsibility to seek additional instruction and supervision when faced with an unfamiliar practice or procedure. Remember that it is not possible for the nurse to meet every single patient’s needs.

The laws that formally define and limit the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse’s responsibility to know the nurse practice act that is in effect for the geographic region. One can write to the board of nursing in a given state, or access

Box 2-4 Common Breaches of the Standard of Care

Practice

  • Failure to use proper judgment
  • Failure to properly assess
  • Failure to properly administer medication
  • Failure to protect patients from burns
  • Failure to properly maintain the airway
  • Failure to restock crash cart
  • Failure to honor advance directives
  • Failure to take an accurate and thorough history
  • Failure to provide a safe environment
  • Failure to properly administer injections
  • Failure to go through hierarchy to get the care needed
  • Failure to detect that the patient has an allergy
  • Failure to protect the patient from abuse
  • Failure to prevent abuse, neglect, or injury by other patients
  • Failure to obtain physician orders—practicing outside the scope of nursing practice by writing orders
  • Failure to practice safely (by using drugs or alcohol while working)
  • Failure to protect and prevent falls

Monitoring

  • Failure to properly monitor
  • Failure to recognize and report signs and symptoms of patient’s deteriorating condition
  • Failure to properly use monitoring equipment
  • Failure to protect against injuries from monitoring equipment
  • Failure to detect or prevent decubitus ulcers
  • Failure to monitor and detect polypharmacy effects on patient
  • Failure to detect signs and symptoms of a medical condition in a timely and proper fashion
  • Failure to detect signs and symptoms of drug toxicity
  • Failure to properly use restraints

Communication

  • Failure to document in a timely and proper fashion
  • Failure to notify physician of laboratory values in a timely and proper fashion
  • Failure to report child or elder abuse
  • Failure to notify physician of a change in status
  • Failure to communicate with other health care personnel about advance directives
  • Failure to properly give discharge instructions
  • Failure to document patient’s status or condition in a timely and proper fashion
  • Failure to document communications between health care providers in a timely and proper fashion
  • Failure to document the need for restraints in a timely and proper fashion
  • Failure to properly document (precharting)

its website, to obtain a free copy of the state’s nurse practice act.

In addition to the boundaries made by the state’s nurse practice act, the employing institution often places limitations on practice. The institution has the right to establish policies and procedures for nursing

Box 2-5 Evidence of Nursing Standards

  • Practice protocols, contracts, practice agreements, employment agreements, and personnel or employee manuals
  • Agency policy and procedure manuals
  • State nurse practice acts and regulations
  • American Nurses Association Code for Nurses (2001)
  • American Nurses Association Standards of Practice (1995)
  • Accreditation criteria of The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations [JCAHO])
  • Other accreditation standards depending on the practice setting (e.g., National League for Nursing, National Association of Home Care)
  • State and federal licensing laws and regulations that govern health care agencies; state, professional, and occupational legislation and regulations
  • Nursing specialty standards of care and certification
  • Nursing literature, textbooks, and journals
  • Education, continuing education, staff development, and orientation
  • Experience
  • Expert nurse witness, other experts, and peers
  • Customs and usual community practices