Posted Fall 2008
Practicing as a Nurse
Description of Area of Life
A nurse is a person who is educated, trained, and concerned with the diagnosis and treatment of human responses to actual or potential health problems. The practice of nursing includes data collection, diagnosis, planning, treatment and evaluation of patients. Nurses need to always be concerned with the patients’ response to the problem not just the problem itself. Nurses form relationships with their patients to promote, maintain, and restore health. A nurse is guided by humanitarian and ethical principles, the nurse practices in a personal, nurturing, and protective manner to promote health in all areas of patient care. Nurses are ethically and legally accountable for the nursing activities performed and for the actions of others to whom the nurse has delegated responsibility.
A nurse can choose from many different areas of practice, including but not limited to acute care, long term care, hospice, community health, and surgery and clinic settings. Each area of practice has its own unique set of ethics, values, responsibilities, and regulations for the nursing staff to follow. For example an Emergency Room nurse is mainly concerned with keeping their patients alive and well, while a Hospice nurse is mainly concerned with allowing their patients to pass away with dignity and comfort. The rules a nurse must follow may differ depending on the area he/she chooses to practice but the same set of nursing laws and regulations must be followed by all nurses.
In order to become a nurse one must have completed an academic course of study in nursing practice as well as anatomy, physiology, ethics, phsychology, and at times even legal issues. A nurse must attain the title of either a LPN (licensed practical nurse), RN (registered nurse), LVN (licensed vocational nurse), APN (advanced practice nurse), or DNPs (doctorate of nurse practice) before they can become a nurse. Each individual state has authority over its nursing practice and its scope, and licenses must be periodically renewed. Some states even require continued education in the renewal process of a nurses license. Nurses are required to wear scrubs while on the job and many places require nurses to wear nonskid shoes to avoid accidents on wet floors. They are required to constantly maintain cleanlyness in their work areas, as well as maintain personal hygeine to reduce the chance of infection. When it comes to patient care often times they are required to wear latex gloves and follow very stringent procedures when dealing with any bodily fluids.
The most common juridic controls that put a nurse in legal risk are those concerning negligence. According to the law negligence is “the failure to provide a patient with the standard of care that a reasonably prudent nurse would exercise under the same or similar circumstances.”1 In order to prove negligence the nurse must be shown to have had (1) a duty to provide care to the patient and to follow an acceptable standard of care, (2) the nurse failed to adhere to the standard of care, (3) that failure caused the patient injuries, and (4) the patient suffered damages as a result. In addition to negligence claims “charting errors and omissions are a significant source of liability risk for the nurses.” Documentation by the nurse can be used by a defense lawyer to prove that the standard of care had not been met.
Documentation standards have been developed over the years by state laws, the nursing profession, and accrediting organizations such as the Joint Commission. “The U.S. legal system has helped nurses know what must be included to conclude that patient documentation is accurate and appropriate.”
Each state has its own nurse practice act that sets up specific criteria that a registered nurse must follow. These state laws “further outline documentation issues, such as handling of records, falsification of records, and confidentiality” that must be followed by every nurse regardless of work setting or nursing specialty. In addition to these state laws a nurse must also follow standards set by the American Nurses Association (ANA). In this case each nursing specialty area has its own specific set of documentation standards specific to the specialty organization. The ANA’s and the Joint Commission standards are much more stringent than the state laws. As if this isn’t enough, a nurse must also follow documentation guidelines set by the employing facility. This is where in can be risky to the nurse because if the employer guidelines are less strict than those of the state’s nurse practice act it is the individual nurses responsibility to adhere to the higher standards of the nurse practice act, the ANA, and the Joint Commission or she can be held liable for a number of crimes if her documentation cannot stand up to the scrutiny of a prosecuting attorney. The saying goes “If it wasn’t documented, it wasn’t done.” Nurses are taught to document five steps in the nursing process: assessment, planning, nursing diagnosis, interventions, and evaluation. These five steps are in addition to documentation of the patient’s mood, activities, and so on. Nurse’s are even suppose to document safely steps that they take on a regular basis, usually without even thinking, such as “putting up bed side rails” or “placing the call button in reach”. In the busy day of a nurse with five to fifteen patients to take care of and document for such common occurrences often are forgotten when it is time to document. This is a liability to the nurse, especially if a patient somehow falls out of bed and the nurse is unable to prove through documentation that the bedrails were in fact up. With all of these seemingly routine details that require documentation I was surprised to read that nurses are to avoid describing a patient’s behavior as uncooperative, difficult, or combative because doing so puts the nurse at “legal risk.” Does this sound absurd to anyone else? If a patient is combative they are a danger to themselves and the nursing staff. Why can this not be documented? Oh yeah, because the legal system that helped make the guidelines can use such words as “uncooperative” to prove in court that the nurse did not like the patient and therefore did not provide the standard of care required.
The life of a nurse is stressful enough without the added burdensomeness of the constant fear that one day you could be sued for not documenting thoroughly enough. For anyone who has ever worked with or as a nurse is aware that it is often impossible to document a dressing change as soon as it is done (it is falsification of records to do so before the dressing change is completed and the nurse could be reprimanded). Many nurses have little time at all to document, often left to the end of the day where they must recall the important aspects to write down. Many times there isn't enough liscensed staff on the work floor, and the nurses are overworked by their superiors. Nurses also run on very tedious and strenuous schedules and dont have very much leeway for their personal lives. Many nurses say that they often have unrealistic expectations from their nursing managers, and at times a nurse is even given an unsafe patient assignment that could put a nurse in physical harms way when dealing with unruely patients.
Methods of Escaping Juridic Controls
Although many of the laws, regulations, and juridic controls placed on nurses are in place for good reasons there are still ways to escape some of the burdens. One of the main problems with the standards of documentation are that there are too many of them (nurse practice act, ANA, Joint Commission, employing facility, specialty organization). There needs to be one universal set of standards for documentation. Another issue is that the legal system has no right to be giving guidance to nurse documentation standards. By allowing the legal system instruct nurses on “what must be included to conclude that a patient documentation is accurate and appropriate” is to allow them to create opportunities for law suits from which the legal system (lawyers) will benefit. Nurses do not have a say in how lawyers or the legal system works therefore the legal system should butt out. We all know what a sue happy society we live in, we should not help to make nurses targets for frivolous law suits.
In addition, one must take into consideration the workload of the majority of nurses. It is not possible to get all of the documentation done most of the time. Many nurses use their break time, when they know they will not be interrupted, to complete documentation. Documentation needs to be a shared effort between the nursing staff, the therapy staff, the assistant staff, any staff that has contact with that patient should be held responsible for documentation. It would be harder to prove negligence by using the documentation of six individuals that it would of just one.
Most common occurrences in which nurses are held legally liable are in situations where the patient’s condition changes rapidly, such as after surgery, during labor, after the patient has suffered an injury while at the facility, or if the patient has known self-destructive tendencies. A nurse’s failure to contact the patient’s physician about changes in the patient’s condition or failing to describe situations that are out of the ordinary.
The bottom line is that the nurses are overworked, underappreciated, and at constant risk of both medical dangers and legal ones. To affectively lessen the burdensomeness of these juridic controls we need to increase the nursing staff at hospitals and nursing home, maybe even some office settings so that the nurses can form a network of close nit caregivers that can back each other up if/when faced with accusations of inadequate care. By doing this the nurses would have more time to spend with the patients, more time for documentation, possibly less stress, and closer connections to fellow nurses. Nurses also need to have more of a separation between what happens inside the workplace, and what happens outside the workplace so they dont constantly have to worry about doing things outside of work that might put their jobs at risk. Nurses need either more vacation time, or even give them more flexible scheduling; because they often dont have enough time outside of work for family.