Legal Rights/Responsibilities and Informed Consent (Nursing)

00:00 Hi, this is Jessica Spellman. I'll be reviewing legal rights and responsibility of nurses.

00:08 The objectives of this course are to be able to explain the scope and standards of nursing practice; describe the purpose of the Nurse Practice Acts; differentiate between negligence and malpractice; understand the process of informed consent; recognize the legal component of nursing documentation; and realize the nurse's role in client's refusal of treatment, reporting abuse and neglect as well as reporting of unsafe practice.

00:42 The ANA has written the nursing standards of practice to recognize the need and describe and define the elements of a competent nurse.

00:54 The standards help aid nurses in recognizing their legal responsibilities and rights and also it's general enough to apply to all areas of nursing practice in all settings.

01:09 I'd like to review a few definitions. The scope and standards of practice are useful in describing the expectations of a competent nurse.

01:18 Competency is defined as the expected level of performance that integrates knowledge, skills, abilities and judgement. There are six standards of practice that make up this document.

01:32 The ANA outlines the standards using a nursing process model, just like we do in some of our other scope and standards of practice.

01:43 They were last updated in 2010 and they're general enough to apply in all situations in all practice settings. So standard number one is assessment.

01:53 That's the first step in the nursing process. The nurse collects data related to the client's health or situation. Standard number two, they make a diagnosis! The nurse analyses the data and applies it to the situation to determine the needs of the client. Three, the nurse does some outcomes identification.

02:19 The nurse identifies the expected outcomes for the client or the situation.

02:24 Standard four is planning: the nurse designs a care plan to assist the client to meet the expected outcome.

02:31 Standard five: implementation. The nurse implements the plan of care and coordinates care delivery.

02:38 Standard six: evaluation. The nurse evaluates the client's progress toward the identified outcomes and revises the plan if needed. So a few other definitions that the ANA has given us in the scope and standards of practice. It's really important to understand what a standard is and what is meant by scope. So we're gonna go through those definitions also.

03:02 Standards are authoritative statements defined by the profession in which the quality of practice, service or education can be evaluated.

03:13 The standards of practice describe a competent level of nursing care as demonstrated in the nursing process.

03:21 The scope of nursing practice is a little bit different. It doesn't necessarilly speak to the competence of the nurse, but the scope in which the nurse can practice in. So description of the who, what, when, where and why of how the nursing practice addresses the range of the nurse's practice activities common to all registered nurses. So it's dependent upon the education level, experience, role, and population served. A better example would be a community health nurse, who normally takes care of their patient in the community setting, is not able to practice within a hospital on an oncology floor because that would be outside of her scope of practice. She could eventually change to that type of nursing, but there would need to be a change in education, the experience and the population served. So the scope is dependent upon where each nurse practices. The Nurse Practice Acts assign a legal component to the practice of nursing. Where the scope and standards of practice outline what makes a competent nurse, the Nurse Practice Acts are written individually by each State in order to define what the legal components of the nursing profession are. The laws are in place to protect patients from harm as well as lay the rules and regulations for this specific level of nurse's educational and licensure requirements.

05:00 I have a few examples here. These are excerpts from the Ohio Nurse Practice Act.

05:06 It's section 4723,01, and this is just where they define what a nurse is.

05:13 So they use the quotation marks around registered nurse and that means that an individual who holds a current valid license issued under this chapter that authorizes the practice of nursing as a registered nurse.

05:26 Pretty simple but it's in legal language. The second part of this definition in the Ohio Practice Act is they define practice of nursing as a registered nurse. And they say that that means providing to individuals and groups nursing care requiring specialized knowledge, judgement, and skill derived from the principles of biological, physical, behavioral, social and nursing sciences.

05:56 So it's very specific. So we're putting a legal component to the scope and standards of practice.

06:05 So the Ohio Nurse Practice Act goes on to describe what registered nurse functions are.

06:12 And number one, they identify patterns of human responses to actual or potential health problems.

06:19 They execute a nursing regiment through the selection, performance, management and evaluation of nursing actions.

06:27 They assess health status for the purpose of providing nursing care. And they provide health counseling and health teaching.

06:35 They also administer medications, treatments and regiments authorized by an individual who is authorized to practice in the State and is acting within the course of the individual's professional practice. It is a legal responsibility of all nurses to know what is included in their State's Nurse Practice Act.

06:57 So we've talked about the scope and standards of practice, how the Nurse Practice Acts put a legal component on the standards. And hopefully, we are operating within our scope and standards of practice and following the Nurse Practice Acts.

07:15 But sometimes things happen, so the Joint Commission has defined malpractice and negligence, and we're gonna take a few minutes to kind of look at those definitions.

07:26 First is negligence. And negligence is the failure to use such care as a reasonably prudent and careful person would use under similar circumstances.

07:36 This doesn't really have anything to do with a profession per se.

07:42 The general public can be negligent and citizens can get hurt either by negligently operating a motor vehicle or being careless in other ways. So malpractice is when it comes down to the actual profession.

08:01 It's the improper or unethical contact or unreasonable lack of skill by a holder of a professional or official position, often applied to physicians, dentists, lawyers, nurses, and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory.

08:24 So we'll go back to those in a minute, but I kinda wanna explain what torts are.

08:30 Tort is an action or lack of action that harms someone, and there are two types.

08:35 There's an unintentional tort, which is where an action causes harm through negligence or careless or thoughtless behavior, and it may also be called malpractice.

08:49 The intentional tort is an action that was knowingly performed and caused physical or emotional harm to the patient.

08:57 So I'd like to go over an example of an unintentional tort. Here's the situation.

09:03 A nurse administers a 1 litre fluid bolus unintentionally to a patient that is on a 2 litre fluid restriction. The act is unintentional and it is negligent. But is it malpractice? If the patient develops heart failure and pulmonary edema requiring the patient to be intubated and transferred to an ICU, the negligent behavior is considered malpractice.

09:35 So negligence becomes malpractice when these four criteria are met.

09:40 Number one, duty. The duty must have been owed to a patient and the nurse assigned to the patient has accepted the duty they care for that patient.

09:51 The second criteria is breach of duty. So once the nurse has accepted the duty, they have failed in some way to not exercise a degree of care or medical skill that another healthcare professional in the same specialty would have used in an equal situation.

10:08 The third criteria is a damage occured. The patient must have suffered emotional or physical injury while in the care of the nurse, and that injury can be a new one or it can be an agrrevation of an existing injury. In the example with the fluid bolus, if the patient had been in pulmonary edema and heart failure previously, that's not a new condition but it is an exacerbation of an existing condition.

10:36 And fourth criteria, the cause. There must be proof that links the breach of duty by the nurse to the act that caused the patient's injury. Okay.

10:47 So an intentional tort on the other hand, is when the action was knowingly performed and caused physical or emotional harm to the patient.

10:55 There are a few examples of nursing intentional torts that we will review.

11:01 The first is assault, and that is attempting to threaten a patient by harm if they don't do something that you ask them to do. So an example would be: "If you don't take your medication, I will hold you down and make you take them!" That is an example of assault. Battery takes assault one step further and you're actually touching or performing tests and procedures on a patient without their consent.

11:29 A patient refuses and does not consent to have an NG placed, but you place one anyway.

11:35 That is considered battery. Another example of an intentional tort is false imprisonement. And I know it sounds hard to think that that would happen in a hospital, but holding a patient against their will, without their consent, does constitute as false imprisonement. So if a patient wants to leave AMA and you use restraints and all kinds of things to restrain them, to keep them from leaving, that could be considered false imprisonment. And the only time that doesn't apply is when they might harm themselves or another person. But if they're willingly, and are competent enough to make the decision and they want to leave, we can be accused of false imprisonment if we make them stay.

12:23 So informed consent is not just a document that needs signed by the patient, but, in fact, it's a process of making sure that the patient has all of the information they need to make an informed decision about their plan of care. Usually, specifically about a procedure. There's not one specific person that obtains informed consent.

12:45 Physicians, nurses and others work together collaboratively to make sure patients receive the information they need.

12:53 A little bit of information about patients and informed consent. The person giving consent must be mentally and physically competent and be legally over the age of 18 or emancipated from their parents. The consent must be given voluntarily, no forceful measures may be used to obtain it. As in not threatening the patient if they don't sign it.

13:16 The person giving the consent must thoroughly understand the procedure, its risks and benefits, as well as alternative treatments. The person giving the consent has the right to have their questions answered so that they can understand the treatment they are going to receive.

13:34 So informed consent can be written or it can be implied. Written is the process of signing a consent form prior to surgery, that's one example. An implied consent is when a patient verbally agrees to allow the nurse to perform a function such as inserting a IV, changing their dressing, something like that.

13:56 They are giving you consent. The process includes explaining the nature of the test or procedure and how it will be performed; presenting the patient with alternatives to the proposed intervention; educating the patient about the relevant risks, benefits and uncertainties about the procedure, and any alternatives that are available; assessing the patient for understanding information provided as well as answering patient's questions to clarify content and concerns.

14:25 The patient accepting to have the test or procedure performed is also necessary.

14:31 The objective of every State's Nurse Practice Act in regards to documentation is to provide a clear and accurate picture of the care the patient received.

14:41 Nurses have a legal duty to document, but the details are left up to the State as to how documentation in healthcare institutions are performed.

14:55 The purpose of documentation is to create an accurate and factual account of the care of the patient received.

15:01 This may not seem necessary while you're actually providing the care, but going back and looking at the chart at a later date will provide the details of the patient's experience that they received. The legal responsibility of the nurse to document should be reflected in the nursing process and documentation assists with communication between healthcare team members.

15:27 A few things to know about documentation. It is the nurse's responsibility to know the governing laws in the State of practice. And also to know the policies and procedures of the institution that they're practicing in.

15:41 It is very important to know the guidelines from specialty organizations, but those are not legally binding, but they do create a standard of care that could be assigned to a particular patient in a particular setting. Some documentation tips.

16:00 A few dos and donts! Do make sure you have the correct chart.

16:05 Make sure you're charting throughout your shift, at the time of the assessment, the intervention, the evaluation, the education etc. Use only facts, no opinions! Use subjective and objective data and use quotation marks whenever possible to denote what the patient is actually saying. Make sure you're following up on interventions and documneting that. And then document healthcare providers notified and information given and orders received in certain circumstances. What you don't wanna do is chart patient complaints without charting the interventions. So you don't wanna say, "this patient has pain," and then not address what you're gonna do about it.

16:51 You don't wanna paraphrase or assume what patients mean. You don't wanna use unapproved abbreviations.

16:58 You don't want to chart the entire shift at one time. That is a way details get lost.

17:04 And don't forget to chart patient and family education.

17:09 In documentation, there is mandatory reporting of certain circumstances.

17:14 Mandatory reporting outlines that nurses must report a situation or person, even another nurse, that could put the public safety at risk.

17:24 For example, a nurse that is working under the influence of alcohol or drugs, it is mandatory that you report that due to a public safety risk. Mandatory reporting outlines requirements that healthcare professionals must report suspicions about behaviors such as abuse and neglect. Those could be for adult or children.

17:47 And the purpose is to protect the public from harm. Professionals practicing unsafely, abuse and neglect of vulnerable populations such as children and the elderly.

17:58 What must be reported? Specifically, child abuse, elder abuse and/or neglect, unsafe or unethical legal practice by a healthcare provider.

18:10 So let's review our legal rights and responsibilities. The scope and standards of practice developed by the ANA lay the foundation for the nursing profession. The standards of practice describe the functions of a competent nurse and provide a legal component to the scope and standards of practice. Nurse Practice Acts may vary from State to State, and the outline of rules and regulations enforced for the nursing profession in that State.

18:39 Nurses need to be knowledgeable of the laws and abide by them in clinical practice.

18:45 The Nurse Practice Act is enforced by the State Board of Nursing and is in effect for the protection of the public. Negligence and malpractice are unintentional torts.

18:57 Duty, breach of duty, damages and cause need to be present in malpractice cases.

19:04 Intentional torts like assault and battery are other ways that patients can be harmed.

19:09 Also remember that informed consent can be expressed verbally or written or it can even be implied. So obtaining written consent is a process, not just the form that needs filled out. And it includes all members of the healthcare team in providing patients the necessary information they need to make an informed decision.

19:34 Documents like the scope and standards of practice and the Nurse Practice Acts in each State help outline the legal responsibility of nurses.

19:43 That is standard of care that nurses are held accountable to in cases of negligence and malpractice.

19:50 Negligence and malpractice are unintentional torts. Duty, breach of duty, damages and cause need to be present in malpractice cases. Intentional torts like assault and battery are other ways that patients can be harmed. Documentation is a legal requirement of nurses.

20:07 It should reflect the care the patient received while in the healthcare setting. Reporting of child abuse, elder abuse or neglect, as well as unsafe practice by other practitioners is mandatory in order to protect the public from harm.

20:23 Staying knowledgeable about legal requirements in the nursing profession is the responsibility of every nurse.

20:31 This has been legal rights and responsibilities, and I'm Jessica Spellman.