05Jones Leadership(F)-ch 05 68 1/14/07 3:35 PM Page 68 Understanding Organizations REFERENCES Aiken, T.D., & Catalano, J.I (1994) Legal, ethical and political issues in nursing Philadelphia: FA Davis American Nurses Association (1998) Standards for nurse administrators Kansas City, MO: Author American Nurses Association (1988) Standards for nurse administrators Kansas City, MO: Author American Nurses Association Committee on Ethics (2001) Code for nurse with interpretative statements, Washington, DC: American Nurses Association Beauchamp, T.L., & Childress, J.F (2001) Principles in biomedical ethics (5th ed.) New York: Oxford University Berzweig, P (1996) The nurse’s liability for malpractice (6th ed.) New York: Mosby Black’s law dictionary (6th ed.) (1996) St Paul: West Brannigan, M.C., & DeGrazia, D (2001) Health care ethics in a diverse society Mountain View, CA: Mayfield Burkhardt, M., & Nathaniel, A (1998) Ethics & issues in contemporary nursing Albany, NY: Delmar Publishers Chambliss, D.R (1996) Beyond caring: Hospitals, nurses, and the social organization of ethics Chicago: University of Chicago Press Cofer, M.J (1998) How to avoid age bias Nursing Management, 29(11), 34–36 Creighton, H (1986) Law every nurse should know (5th ed.) Philadelphia: W.B Saunders Curtin, L (2001) The first 10 principles for the ethical administration of nursing services Nursing Administration Quarterly, 25(1), 7–13 DeMello, A (1985) One-minute wisdom New York: Doubleday Devettede, R.J Pretrial decision making for health care ethics: Cases of concepts (2nd ed.) Washington, DC: Georgetown University Press Edwards, P.A., & Roemer, L (1996) Are nurse managers ready for the current challenges of health care? 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Boston: Jones and Barlett Publishers Furrow, B.R., Johnson, S.H., Jost, T.S., & Schwartz, R.L (1991) Liability and quality issues in health care St Paul: West Giordano, K (2003) Examining nursing malpractice: A defense attorney’s perspective Critical Care Nurse, Apr(23) Guido, G.W (2001) Legal and ethical issues in nursing (3rd ed.) Upper Saddle River, NJ: Prentice Hall Hall, J.K (1990) Understanding the fine line between law and ethics Nursing 90(10), 37 Hellinghausen, M.A (1996) Providers face more liability as duties grow Nursing & Allied Health Week, 1(15), Hill, T.C., & Zweig, R.M (2003) Immanuel Kant: Groundwork for the metaphysics of morals, New York: Oxford University Press Iowa Hospital Association (1991) The patient self-determination act of 1990: Implementation in Iowa hospitals Author Kelly, C (2000) Nurses’ moral practice: Investing and discounting self Indianapolis: Sigma Theta Tau, International Center Nursing Press LaDuke, S (2000) What to expect from your attorney Nursing Management, 31(1), 10 Mappes, T.A., & DeGrazia, D (2002) Biomedical ethics (5th ed) Boston: McGraw Hill Massachusetts Nursing Association (2003) MNA Publication, May, 11 Moy, M.M (2005) A year later: EMTALA final rule clarifies obligations ED Legal Letter, 16(4), 37–48 Moy, M.S (2003) EMTALA revisions provide clearer explanation of critical terms ED Legal Letter, 15(2), 13–24 Munson, R (2004) Intervention and prediction: Basic issues in medical ethics (7th ed.) Victoria, Australia: Thomas Wadsworth Nguyen, B.Q (2000a) ADA coverage: Defining who is “qualified individual with a disability.” American Journal of Nursing, 100(3), 87 Nguyen, B.Q (2000b) If you’re replaced by a younger nurse American Journal of Nursing, 100(3), 82 Olson-Chavarriaga, D (2000) Informed consent: Do you know your role? Nursing 2000, 30(5), 60–61 Patient Self-Determination Act/Omnibus Budget Reconciliation Act of 1990, Pub L No 101–508, Sec 4206; 42 U.S.C Sec 1395cc(a)(1) Pohlman, K.J (1989a) Legal issues in nursing: DNR? CPR? Focus on Critical Care, 16(3), 224–225 Pohlman, K.J (1989b) Legal issues in nursing: Nursing negligence Focus on Critical Care, 16(4), 296–298 Pohlman, K.J (1990) Against nursing advice? Focus on Critical Care, 17(1), 57–58 Pozgar, G.D (1999) Legal aspects of health care administration (7th ed.) Gaithersburg, MD: Aspen Press Raphael, D.D (1994) Moral philosophy (2nd ed.) New York: Oxford University Press Rawls, J (1971) A theory of justice Cambridge, MA: Harvard University Press Steckler, S.L (2000) Nursing case law update Journal of Nursing Law, 7(1), 55–64 Yoder-Wise, P (2003) Leading and managing in nursing (3rd ed.) St Louis: Mosby 06Jones Leadership(F)-ch 06 1/15/07 6:42 PM Page 69 chapter Regulating Nursing MARY O’KEEFE, RN, PHD, JD CHAPTER MOTIVATION “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”1 Disclaimer2 CHAPTER MOTIVES ■ ■ ■ ■ ■ ■ ■ ■ ■ Explore nursing regulation through nursing practice acts Define nursing standards and competencies Identify nursing standards specific to advanced practice, management, and informatics Analyze evidence-based nursing practice as the standard of care Analyze nursing research as the mechanism to provide evidence-based nursing and best practice Explore accreditation as nursing regulation Explore policies and procedures as nursing regulation Explore regulations of staffing to provide standardized patient care Discuss state and federal legislative and administrative regulation of nursing 1American Nurses Association (2001 June) Code of Ethics for Nurses Retrieved December 14, 2004, from http://www.nursingworld.org/ethics/chcode.htm 2The information contained in this chapter is not intended to be legal advice Further, this information related to regulating nursing is dynamic, and may have changed or be changing at any point Therefore, when seeking legal advice regarding any of the information contained in this chapter, retain the legal counsel of an attorney 69 06Jones Leadership(F)-ch 06 70 1/15/07 6:42 PM Page 70 Understanding Organizations N ursing practice is regulated on the state and federal level Nursing regulation “began as a simple registry process to protect the nursing title and the public” (Flook, 2003, p 160) The primary purpose of nursing regulation today is not only protecting the public through a defined nursing practice but also regulating nursing education and “overseeing the competence of nurses through licensing and disciplinary rules and regulations” (Flook, 2003, p 160) The authority to license and discipline the nursing profession is granted to each state’s board of nursing, often called the board of nurse examiners (BNE) through state legislation creating a nursing practice act and mechanisms for licensure The Nursing Practice Act At the state level, nursing is regulated by the nursing practice act, which provides for licensure as a registered nurse A state’s act defines nursing and the standards of care The nurse is licensed to practice under the state’s act The act defines specifically what the reasonable nurse is licensed to to meet the standards of patient care STANDARD OF CARE FOR THE REGISTERED NURSE The standard of care (Box 6-1) is “that degree of care, expertise and judgment exercised by a reasonable and prudent nurse under the same or similar circumstances [through] use of nursing process” (O’Keefe, 2001, pp 552–553) Licensure is the “mechanism by which a state establishes and verifies compliance with [nursing] standards” (O’Keefe, 2001, p 542) The act regulates nursing through the BNE, which oversees the nurse’s compliance with the nursing standards and grants licensure Certification acknowledges nursing competence at an advanced level of practice Gunn (1999, p 135) believed that society and patients in general have grown skeptical of the willingness of the nursing profession to police itself In the 1970s, skepticism coupled with a malpractice crisis forced regulators of nursing practice to move beyond “one-time testing for a lifelong credential, to other alternatives for assuring competency in nursing Box 6-1 BNE Rule 217.11: Standards of Nursing Practice for the Registered Nurse (22 Tex Admin Code 217, Part 11, 2004) The Texas Board of Nurse Examiners is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure 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 (3) Standards Specific to Registered Nurses The registered nurse shall assist in the determination of healthcare needs of clients and shall: (c) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (d) performing comprehensive nursing assessments regarding the health status of the client; (ii) making nursing diagnoses that serve as the basis for the strategy of care; (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client’s responses to nursing interventions; (B) Delegate tasks to unlicensed personnel in compliance with 22 Tex Admin Code chapter 224, relating to clients with acute conditions or in acute care environments, and chapter 225, relating to independent living environments for clients with stable and predictable conditions practice.” Currently, the focus varies on a state-bystate basis, from voluntary to mandatory requirements for continuing education as a mechanism for either continuing certification or recredentialing Certification involves “examinations developed by professional organizations which provide certification of a claim to competence at a certain level of practice” (O’Keefe, 2001, p 532) The graduate nurse must possess the competence to practice independently, a declaration that must be demonstrated and supported by documentation (Texas Board of Nurse Examiners, 2004) A nursing competency is the skill and behavior required to perform the role of a nurse 06Jones Leadership(F)-ch 06 1/15/07 6:42 PM Page 71 Regulating Nursing STANDARDS OF CARE FOR ADVANCED NURSING PRACTICE By definition, an advanced practice nurse (APN) is “a registered professional nurse who is prepared for advanced nursing practice by virtue of knowledge and skills obtained through a post-basic or advanced educational program of study, [and] acts independently and/or in collaboration with other health care professionals in the delivery of health care services” (O’Keefe, 2001, p 529) Regulating Advanced Practice Advanced nursing practice is regulated by and built upon standards of care for the registered nurse, identified within each state’s nursing practice act See Box 6-2 for the definition of an APN in Texas Prior to1971, most states made it illegal for any nurse to perform diagnosis or prescribe treatment Regulation of APNs and programs for their preparation by boards of nursing vary from state to state Fenton and Thomas (1998) reported that boards have authority only to regulate advanced practice through: (1) the recognition of the APN and (2) the setting of standards and scope of practice Fenton (1998, p 78) noted the “lack of consistent APN educational program standards and experiences and criteria for recognition of APNs was problematic at the levels of accreditation, certification, and regulation.” As a consequence, the Texas Board of Nurse Box 6-2 BNE Rule 221.1(3): Definition of an Advanced Practice Nurse (22 Tex Admin Code 221.1(3), 2001) (3) Advanced practice nurse—A registered nurse approved by the board to practice as an advanced practice nurse based on completing an advanced educational program acceptable to the board The term includes a nurse practitioner, nurse-midwife, nurse anesthetist, and clinical nurse specialist The advanced practice nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings including but not limited to homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice The advanced practice nurse acts independently and/or in collaboration with other health care professionals in the delivery of health care services 71 Examiners developed a model designed to ensure the education and recognition of the APN, emphasizing both professionalism and public safety (Fenton & Thomas, 1998) For example, APNs practice via protocols or other written authorizations See Box 6-3 for a definition of these protocols and other written authorizations under the Texas Nursing Practice Act Roemer (1977) reported that states have been increasingly liberalizing the scope of nursing functions, making it possible for the APN to assume functions formerly not within the nurse’s scope of clinical practice In some states, some of these advanced practice functions are allowed under doctor’s supervision In other states, especially in rural areas, the APN may function independently The independent action, however, such as dispensing medications, may be limited to a single course of treatment Midwives tend to function independently According to Roemer (1977), nurse-midwives have been accepted as extensions of scarce medical facilities, generally authorized to provide prenatal and postpartum care, handle normal deliveries, and family planning work, including fitting diaphragms and inserting and removing IUDs Moreover, courses for family planning nurse practitioners have been set up across the United States Graduates may, with medical direction: (1) perform bimanual pelvic examinations and breast examinations; (2) prescribe contraception; (3) fit diaphragms, insert IUDs, and examine vaginal secretions microscopically; and (4) refer patients with problems to physicians Roemer (1977) also reported a California program of both registered and nonregistered nurses trained as women’s health specialists, who make routine examinations in both pregnant and nonpregnant women, to give family planning advice Non-RN family planning specialists being trained included (1) licensed vocational nurses, (2) baccalaureate degree holders in non-nursing fields, and (3) qualified persons with less formal education This 24-week course was authorized under the California State Department of Health According to Roemer, the use of the APN would (1) help make family planning and well-baby services more generally available and (2) conserve valuable physician time for those cases that need greater skill and training As standards of nursing care vary from state to state, so does the regulation of the APN Ponto, 06Jones Leadership(F)-ch 06 72 1/15/07 6:42 PM Page 72 Understanding Organizations Box 6-3 BNE Rule 221.13: Core Standards for Advanced Practice (22 Tex Admin Code 221.1(3), 2001) (a) The advanced practice nurse shall know and conform to the Texas Nursing Practice Act; current board rules, regulations, and standards of professional nursing; and all federal, state, and local laws, rules, and regulations affecting the advanced role and specialty area When collaborating with other health care providers, the advanced practice nurse shall be accountable for knowledge of the statutes and rules relating to advanced practice nursing and function within the boundaries of the appropriate advanced practice category (b) The advanced practice nurse shall practice within the advanced specialty and role appropriate to his/her advanced educational preparation (c) The advanced practice nurse acts independently and/or in collaboration with the health team in the observation, assessment, diagnosis, intervention, evaluation, rehabilitation, care and counsel, and health teachings of persons who are ill, injured or infirm or experiencing changes in normal health processes; and in the promotion and maintenance of health or prevention of illness (d) When providing medical aspects of care, advanced practice nurses shall utilize mechanisms which provide authority for that care These mechanisms may include, but are not limited to, Protocols or other written Sabo, Fitzgerald, and Wilson (2002) report that many other state boards of nursing are examining advanced nursing practice to determine a process to recognize and regulate such practice for the purpose of eventual uniformity of the nursing law For example, in 1999, Minnesota state law was redesigned to define and provide protection for advanced practice registered nurses The Minnesota Board of Nursing convened to develop (1) recommendations regarding issues of certification, (2) criteria for determining acceptable certifying organizations, (3) procedures in the event of examination failure, and (4) a process for communicating this information to the nursing community (Ponto et al., 2002) Scope of Practice for Clinical Nurse Specialists A clinical nurse specialist (CNS) is an APN who has specialized education and training in one clinical area For example, the psychiatric CNS focuses authorization This shall not be construed as requiring authority for nursing aspects of care (1) Protocols or other written authorization shall promote the exercise of professional judgment by the advanced practice nurse commensurate with his/her education and experience The degree of detail within protocols/policies/practice guidelines/clinical practice privileges may vary in relation to the complexity of the situations covered by such Protocols, the advanced specialty area of practice, the advanced educational preparation of the individual, and the experience level of the individual advanced practice nurse (2) Protocols or other written authorization: (A) should be jointly developed by the advanced practice nurse and the appropriate physician(s), (B) shall be signed by both the advanced practice nurse and the physician(s), (C) shall be reviewed and re-signed at least annually, (D) shall be maintained in the practice setting of the advanced practice nurse, and (E) shall be made available as necessary to verify authority to provide medical aspects of care (e) The advanced practice nurse shall retain professional accountability for advanced practice nursing care on treating the patient in the clinical area through patient or staff education, consultation with psychiatric nursing or other staff, and structuring patient therapies See Box 6-4 for the scope of practice for the APN Heitkemper and Bond (2004) believed that the CNS is critical to providing leadership to improve patient care, advancing nursing practice, and strengthening health-care delivery systems The scope of nursing practice has been expanded to encompass nursing via various technologies For example, with the advent of telenursing, states must now extend the scope of practice across state boundaries The Effects of Telenursing Upon Expansion of Nursing Practice Acts Nursing practice acts—developed by the individual states—traditionally have regulated the nurses that practice within the state Telenursing challenges this boundary-driven regulation Telenursing is ... nurse shall know and conform to the Texas Nursing Practice Act; current board rules, regulations, and standards of professional nursing; and all federal, state, and local laws, rules, and regulations... safety, and rights of the patient.”1 Disclaimer2 CHAPTER MOTIVES ■ ■ ■ ■ ■ ■ ■ ■ ■ Explore nursing regulation through nursing practice acts Define nursing standards and competencies Identify nursing. .. evidence-based nursing and best practice Explore accreditation as nursing regulation Explore policies and procedures as nursing regulation Explore regulations of staffing to provide standardized