You probably address legal concepts when talking about documentation, medication administration, and delegation. But most orientation programs do not allot specific time to legal issues in general as there is constant pressure to conduct orientation more efficiently and in less time.
How can you introduce this additional information into an already crowded orientation schedule? One possibility is to develop a basic handout and include some scenarios for general discussion or self-study. Remember that you are not expected to offer a continuing education program on legal issues in nursing. This is beyond the scope of orientation. You are simply introducing some basic concepts and stimulating interest. Let's start with some basic legal concepts and a handout that will guide your discussions.
Laws and regulations
Each state has its own Nurse Practice Act, which contains information about the specific scope of practice and educational requirements. Each act also contains statements that prohibit nurses from performing tasks determined to be within the scope of medical practice.
You cannot review the entire Nurse Practice Act in orientation, but you should encourage nurses to obtain a copy of it from the State Board of Nursing and to become familiar with it. You should also include information about avoiding conflicts with employing organizations and volunteer organizations. Tell orientees that their employers cannot expand the scope of their practice to include actions that are prohibited by the state's Nurse Practice Act. All nurses have a legal obligation to practice within their Nurse Practice Act limits (Follin, 2004).
The first three items on the sample handout (p. 3) deal with your state's Nurse Practice Act and legal obligations pertaining to it. Exceeding those limits may result in disciplinary action by the State Board of Nursing or even loss of license. The next items deal with scope and standards of specialty practice and regulatory bodies. You don't need to go into great detail; simply mention those that are most applicable to your organization, such as The Joint Commission (particularly the National Patient Safety Goals) and American Nurses Association (ANA) Standards of Practice. Individualize the handout so it is applicable to your state and organization.
Delegation
It's a good idea to mention delegation responsibilities, especially to orientees who are newly licensed RNs. RNs may delegate to another RN, an LPN, and/or an unlicensed staff member, such as a nursing assistant. However, the RN may only delegate tasks to persons who are competent to perform them and who are able to perform them as part of their legal scope and standards of practice. The delegating RN is still ultimately responsible for his or her patient's care, even if some tasks are delegated to others (Follin, 2004).
The RN needs to know the competency, skills, and abilities of the persons to whom he or she is delegating tasks. He or she must evaluate these persons on an ongoing basis, continually evaluate patients, and report persons who are incompetent or who fail to perform tasks safely.
Elements of professional malpractice
Professional malpractice cases review the patient care provided to determine whether deviations from the appropriate standard of care took place. This is usually initiated with a review of the medical record. Standards of care are measured according to practice acts, professional scope and standards of care, and organizational policies and procedures.
To prove liability for malpractice, four elements must be shown (Morales, 2009):
Duty. There must be a duty that is owed to the patient as indicated by the nurse-patient relationship. This can be interpreted broadly. As a simple example, nurses have a duty to provide a safe environment for patients. Patients must be able to reach their call bell when they need to get out of bed to go to the bathroom. Part of the safe environment, and nurses' duty, is to make sure patients' call bells are within reach and they know how to access them.
Breach of duty. Breach of duty means nurses fail to fulfill their duty to the patient. Suppose nurses fail to adequately assess patients' environment. The nurses know a patient needs assistance to ambulate to the bathroom but fail to secure the call bell within the patient's reach. The patient can't reach the call bell and calls out for help. Unable to wait until someone hears him, the patient gets out of bed and falls. The duty to the patient was breached.
Injury. To prove liability, injury must occur as a result of the breach of duty. The patient who fell in an attempt to get to the bathroom breaks his hip as a result of the fall. He was injured due to a breach of duty. The injury must also result in monetary damage. In this example, the additional expense of hip surgery and extended hospitalization are part of the damages.
Causation. There must be a direct cause and effect between the patient's injury and the breach of duty. This is usually the most difficult element to prove at a malpractice trial. In the case of our example, it must be proved that had the call bell been within reach, the patient would not have been injured.
In addition to discussing the handout, develop case scenarios of your own that illustrate the four elements of negligence. You may also want to develop a mock court role-play scenario. Your legal department can be a big help when developing mock courts.
Legal tip: This article is intended as an introductory guide, not as legal advice. When developing legal tools, consult with your organization's legal and risk management department. Issues to address, in conjunction with your legal department, include advance directives, living wills, and hospital policy regarding employees witnessing patient wills.
References
Follin, S.A. (Ed.). (2004). Nurse's Legal Handbook (5th ed.). Philadelphia: Lippincott Williams & Wilkins.
Morales, K. (2009). "Elements of medical malpractice." Retrieved December 18, 2009, from www.nursetogether.com/tabid/102/itemid/1406/Elements-of-Medical-Malpractice.aspx.
An 85-year-old hospital patient faces first-degree assault and other charges after allegedly shooting and wounding a nurse inside Danbury (CT) Hospital. Stanley Lupienski, who was being treated at the hospital, shot a nursing supervisor three times in the cardiac care department, on the eighth floor, at 2:37 p.m. on March 2, police said. The nurse was rushed to the emergency room, where he was in stable condition, hospital officials said.
Washington, DC's largest private hospital has fired 11 nurses and five support staff members who failed to make it to work during the back-to-back snowstorms that paralyzed the region in February. Dozens of staff members at Washington Hospital Center face internal investigations, union representatives say, and it is unclear how many employees will lose their jobs. The nurses union, Nurses United of the National Capital Region, has filed a class-action grievance with the hospital, the Washington Post reports.
It is a bit of an industry joke: Hospital employees are statistically among the most unhealthy Americans, particularly when it comes to cardiovascular health.
To combat this fact, Spartanburg (SC) Regional Healthcare System—designated as an ANCC Magnet Recognition Program® (MRP) organization in 2005—sought to improve the health of its 5,000 employees as it aimed to reduce the comparatively high rate of deaths from heart disease in the region—556 versus 536 per 100,000 nationwide.
And with planning and effort, it did. Spartanburg successfully inspired employees to exercise, helped employees lose 1,759 lb. collectively, and identified 250 employees with elevated systolic blood pressure, while simultaneously improving the overall health of its community and laying a blueprint for other hospitals to follow. This included the education of three OB/GYN groups, one family medicine group, the Spartanburg Regional Medical Center (SRMC) employee health department, and all of the medical residents who rotated through the chest pain department, as well as two employee wellness challenges and screenings.
SRMC is also part of the HeartCaring® Program, a Spirit of Women national campaign focusing on outreach and education of heart health issues.
"What we realized was that we needed to give this information out and take care of our own employees," says Mary Mathes, executive director of women and children's services at SRMC.
Mathes says there was an opportunity to set up an employee health program that could reach a large number of employees, and to do so in a gender-specific way—remarkably, more than 80% of Spartanburg's employees are women. Not only could the hospital target a massive percentage of its workforce, but it could also tap into behaviors female healthcare providers tend to exhibit.
"This information will not only go out to our female employees; they would take this information back to their homes," says Mathes.
This was a deliberate thought—organizers knew that women generally make the healthcare decisions for their families, "and so, if we could educate them, we knew this information would go into the home and into the community," says Mathes.
Why do nurses and other healthcare providers so often exhibit signs of poor health?
"I think healthcare providers in general put themselves last," says Mathes. "They work long shifts and then they have to multitask lives outside the job. We recognize that as the healthcare field."
Thus, Spartanburg's goal was to help its employees realize that their own health is just as important as the health of their patients.
Distributing information
As a member of the Spirit of Women Network, Spartanburg was provided a wealth of evidence-based information and materials that could be distributed to staff.
"All we had to do was find a vehicle to provide this information to our staff," says Mathes.
Every employee has an annual health evaluation at the hospital. Organizers realized that one place where every employee would eventually find themselves—and where they would be in the right frame of mind to think about their own health—was the waiting area for these evaluations.
"There was an opportunity there to provide educational materials, and then to have them meet face-to-face with a nurse practitioner," says Mathes.
J.T. Smith, RN, MSN, BC, CVN-1, chest pain center coordinator at Spartanburg, is in charge of education for clinical healthcare providers. Smith educated the nurse practitioners and physicians on the program.
"We found there was a knowledge deficit," says Smith. "When asked what they thought the No. 1 killer in women was, the majority said breast cancer, when it's heart disease."
With the nurse practitioner actively providing information and printed materials as takeaways in the waiting area, these annual evaluations became a good opportunity for staff outreach.
The importance of 'when'
To maximize the program's impact, SRMC implemented its outreach program early in the year.
"We did it at a strategic time of year," says Smith. "In January, everyone is motivated, ready to change their lifestyle. That's when we said, 'Let's look at your heart health.' And this leads into heart month [February], when we offer different venues for heart education."
SRMC is particularly interested in employee health—beyond evaluation, cholesterol screenings, and the like, the hospital also has a half-mile indoor walking track where staff members can squeeze in a workout during their lunch break. Because of the success of the indoor track, the facility has been able to rally support to get a larger outdoor track built as well.
Once under way, the program caused a welcomed issue—education materials were flying out the door.
"The biggest problem was keeping up with materials," says Mathes.
Supply had trouble keeping up with demand, prompting frequent calls from employee health center and physician practices for additional materials.
"Honestly, sometimes getting into physician offices was a problem initially as we got them to realize this was a program that could benefit their patients, but once we got into the offices, [Smith] was able to describe what we were doing, and they embraced it," says Mathes.
Spartanburg took an MRP concept and turned it inward. "With [the MRP], when you think about your nurse practice model, our theory is caring for our own and reaching out," says Smith. "Caring for our own is paramount, that we not forget that we have a large population of women are right here in our institution."
Success stories
SRMC offers blood pressure screenings every February. In one year, it took more than 500 blood pressures and found that 50% of the employees who were screened had elevated systolic blood pressure. The hospital was able to provide guidance for those employees, whether through advice, treatment, additional tests, or further evaluation.
"It sounds very simple, but I'll venture a guess that if you talk to healthcare providers . . . we take blood pressures every day but very seldom take our own or each others'," says Smith. "We felt there was possibly a need there, and unfortunately we were right."
And once those basic healthcare needs were met, the facility knew its employees would pass on the information they learned. "Part of our education with our employees was knowing they would take it back to the bedside," says Mathes. "This information could be passed on to their patients when they're ready to go home. Just educating our staff would help our patients."
The next step is to demonstrate continual improvement and growth. This means keeping things interesting.
"The other thing is to keep up with the employees," says Smith. "We have to keep offering them opportunities to learn more about their risks and how to live a healthy life. We have to be creative and keep our employees interested in clever ways."
A small room just off the admissions area at Tufts Medical Center in Boston contains what many in the facility describe as the nerve center of the hospital. It looks like the bridge of the Starship Enterprise. Multiple plasma screen monitors blink with yellow, green, and blue squares.
Employees sit seated in front of the monitors, analyze the colors and icons as they enter new data into the computers below, and relay information to callers.
To the outside observer, the screens look like a bunch of flashing lights, but these screens are actually a snapshot of the entire facility. They are a part of Tufts' RapidView system, powered by McKesson's Horizon Enterprise Visibility™ solution.
RapidView isn't a tool that benefits just one department. The system helps improve every aspect of the facility, from housekeeping to employees to physicians.
"RapidView allows us to access timely, correct information so we can better align patient needs with our resources," says Terry Hudson-Jinks RN, MSN, vice president of patient care services at Tufts Medical Center.
Reading the board
This is where June Stark, RN, BSN, MEd, director of case management and quality support services at Tufts Medical Center starts her day—in the admission discharge transfer (ADT) center. With just a three- to five-minute scan of the screens, Stark can tell whether Tufts has enough discharges to meet the scheduled admissions.
"There is an art to it," Stark says. "After a while you can just look at the screens and know if it's going to be a busy day."
Each screen in the ADT center represents a floor of the hospital and each square represents a room. The color of a room is based on what type of patient is occupying the bed—a green room means the patient is an inpatient, blue means the patient is receiving observation services, etc.
This morning Stark notices the squares on one floor are almost all solid green, which means discharge orders have not been written for those patients. She sends a page to the nurses and case managers on that floor telling them to make sure the latest data are in the system and to promote additional discharges.
When Stark checks the boards later in the day she hopes to see a few green and white striped squares where green squares appeared in the morning. Green and white striped squares mean a physician wrote a discharge order and a discharge is pending.
A striped square also displays how many minutes have passed since the physician wrote the order. This makes it easy to track how quickly patients are discharged after the physician writes the order.
Improving patient flow
RapidView system is partly a response to the Massachusetts mandate that EDs can no longer divert patients, says Melissa Culkins Bair, RN, MS, nursing director of the ADT Center at Tufts Medical Center.
"One of the reasons we came up with the bed board [RapidView] was so that we could improve patient flow because we couldn't have the ED closing the door," Culkins Bair says.
RapidView improves patient flow by providing up-to-the-minute information for healthcare professionals, admitting staff members, and housekeeping staff members. Before RapidView, there was no mechanism to track such information.
"We worked in silos before centralizing patient access with RapidView. We didn't always have up-to-date information on unit-based throughput, leaving us uninformed on the clinical priorities," Culkins Bair says.
Electronic timers within the RapidView system keep track of everything.
For example, when staff members discharge a patient, this is communicated automatically by messages fed from clinical information systems to all employees by turning the green and white square brown, which means the room is dirty.
The housekeeping staff members and all other hospital employees on that floor see the brown square on one of the many LCD screens mounted in the common areas. Housekeeping goes to the brown room and signs in that he or she has begun cleaning. This turns the square brown and white and also starts the clock. Once finished, the crew member signs off that the room is clean and moves on to the next brown square.
This time-keeping feature makes staff members more accountable because it allows administrators to see how the patient moves along the continuum in real time. If it took three hours longer than expected to clean the room, managers can investigate the reason for the delay and take steps to improve the process.
RapidView also makes the ADT Center staff members' job a lot easier. With a scan of the screens, they can determine whether the hospital has any open beds, when beds will be open, whether a patient has an infectious disease, along with other patient information.
"The key to RapidView is that it is correct and it is timely," says Hudson-Jinks. "Because the variables keep changing minute to minute, your information cannot be 20 minutes old."
According to Hudson-Jinks, this access to timely information allowed Tufts to lower length of stay, treat more patients in 2009, and turn away fewer patients in acute need from surrounding communities.
Improving patient quality
"The thing that makes this system different is that it's not just a bed tracking system. It has clinical features," Culkins Bair says.
RapidView allows the medical staff to get an idea of the patient's case at a glance. For example, if the patient is on fall precaution, deidentified text appears on the screen that communicates this information to healthcare professionals. Healthcare professionals see this information on their floor's screen.
Icons also help healthcare professionals track where a patient is in the facility. If a patient is in radiology for testing, an icon appears on his or her room, and a timer starts. This way, staff members can tell family, visitors, and other healthcare professionals where the patient is and when he or she is expected to return.
There are also icons that appear to tell healthcare professionals that lab work has come back. A trained observer can even tell whether the results were normal or abnormal based on the icon's color.
In addition, RapidView has changed the way Tufts structures its ADT process. An RN works alongside an ADT Center staff member to ensure that patients are placed properly on the front end according to their condition.
Saving time
The RapidView system is also saving the Tufts staff a lot of time. The ADT Center staff no longer needs to make as many calls to each floor asking how many discharges are expected for the day or how many beds are available.
"Before, we relied on too many people to call and tell us information, whereas now, the information comes to us," says Hudson-Jinks.
As a result, the hospital's processes are streamlined and that in turn allows staff members to handle high volumes with relative ease.
This article was adapted from one that originally appeared in the January 2010 issue ofCase Management Monthly, an HCPro publication.
"Why are nurses so mean to each other?" asks Theresa Brown, RN, in this blog posting published online by the New York Times. Brown thinks it’s time the profession discussed the issue more openly, saying "A majority of nurses do not bully on the job, and that majority needs to set a new tone. We have to come out of the corner, stop allowing our co-workers to tear at one another's flesh and instead speak up."