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    Negligence and theNurse

    Negligence and theNurse

     Negligence and theNurse

    Nursing practice is a scientific process, and as Nurseshavea responsibility to remaincompetent through- healthcare advances and public policy changes, nursing out theircareer.Topracticecompetently,nursesmusthave has tochangeaswellandadapt tochangingenvironments severalkeyelements thatguide theprofession inplace:

    (1) whilepracticingwithin the codeof ethics at all times. the education undertaken must be accredited to meet a standard,

    (2) a system for certification and licensure, NEGLIGENCE and

    (3)acodeofethics that form thebasisof theirevery- Negligence is defined asdoing something or failing to do1 day work. Regulatory bodies determine the minimum something that a prudent, careful, and reasonable nurse standards for nursing competence and authorization to 2 would do ornotdo in the same situation. It is the failure practice. Employers ensure that thework environment tomeet accepted standards of nursing competence and enables the nurse to engage in competent practice at nursing scopeofpractice. It isnotbasedonwhat apartic- all times. The nursing profession determines the scope ularnursedeems isappropriate ina situation; it iswhether of practice.Nursing practice has been supported by the thenurseactedwith theknowledgeandskill that is reason-


    ANA) through policy de- ablyexpectedof someonewith thatnurse’seducationand velopment and action, establishment of the scope and training.An importantpoint fornurses to remember is that standards of nursing practice, and implementation of the sometimesacting reasonablymaymean referring toanad-1 Code of Ethics for Nurses with Interpretive Statements. vanced practice nurse (APN) such as a clinical nurse Thecodeofethics formsacentral foundation for thenurs- specialistwhohas specialty training todealwith the situa- ing profession and guides nurses in their decisions and tion

    Negligence also

    generally refers to actsor failures to1 conduct. The ethical standards set in the code of ethics 2 act that areunintentional rather than intentional. arenonnegotiable in all roles and settings. It is imperative thatpracticingnursesknow thecodeofethics,areaccount-


    able for competent nursing actions, and always practice Professionalmalpracticformofnegligenceand refers within their scope of practice set by regulatory bodies in to negligence committed in carrying out professional the state that theyareemployed.Nurseswhoarenotcom- duties.The standard that isused todeterminemalpractice petent and/or chose to practice outside their scope of is ‘‘What is the care that reasonably should have been practice are breaking the law and place themselves and exercised under the circumstances?’’ In the nursing con- theorganizationwhere theywork foratrisk formalpractice text, did the nurse act with the degree of competence that isexpectedbasedonestablishedstandardswithin their AuthorAffiliations: ClinicalPracticeConsultant,Quality (Ms Jacoby),Clin-

    3 education, training, and scopeofpractice? Harm to apa- ical Effectiveness Team, Regional Quality, Accreditation, Regulation & LicensingDepartment,andCriticalCare/SepsisClinicalPracticeConsultant tient forms the basis of amalpractice case. The code of (Dr Scruth),ClinicalEffectivenessTeam,RegionalQualityandRegulatory ethics states that nurses must recognize incompetent, Services,KaiserPermanente,Oakland,California. unethical, illegal, or impaired practice that places the pa- The authors report no conflicts of interest. 1 tient at risk. Once recognized, the nurse has a duty to Correspondence: ElizabethAnn Scruth, PhD,MPH,RN, CCNS, CCRN, inform theappropriateperson tomitigate the risk to thepa- FCCM, Clinical Effectiveness Team, Regional Quality and Regulatory Services, 14th fl (144W11), Bayside, 1950 Franklin St, Oakland, CA tient.Nursesmustalsoescalate toahigherauthority ifonce 94612 (elizabeth.scruth@kp.org). reported the issue isnotdealtwith, including reporting to DOI: 10.1097/NUR.0000000000000301 professional regulatorybodies. A ClinicalNurse Specialist www.cns-journal.com 183 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved


    4: The nurse has authority, accountability,

    3. failure to communicate (including to the physician and responsibility for nursing practice;makes deci- and escalatingwhen the situation is not resolved), sions; and takes action consistentwith theobligation 4. failure to document care in themedical record, and to promote health and to provide optimal care. 5. failure to follow the chain of command Provision 5: The nurse owes the same duties to self 6. failure to act as the patient’s advocate asothers, including the responsibility topromotehealth and safety,preservewholenessof character and integ-


    rity,maintain competence, and continuepersonal and Nurses are accountable for theirown actions and formain- professional growth. taining competency for practice. To protect themselves Provision 6: The nurse, through individual and col- from potentialmalpractice lawsuits, nursesmust practice lective effort, establishes, maintains, and improves according to the standardsofnursingpractice anddegree the ethical environmentof thework setting and con- of specialization.Each statehasanursepracticeact thatall ditions of employment that are conducive to safe, nursespracticingwithin that statemust know and follow. quality healthcare.

    TheCodeofEthics fromANA isaguidingprinciples forall Provision

    The nurse, in all roles and settings, ad- nurses regardlessof the statewhere theywork in.Theclin- vances theprofession through research and scholarly icalnurse specialist servesasan integral rolemodel for the inquiry,professional standardsdevelopment, and the codeofethicsandassistingwith the translationof thepro- generationofbothnursing andhealthpolicy. visionsof the code toRNs to ensure that theyunderstand Provision8:Thenurse collaborateswithotherhealth that they arenonnegotiable. professionals and the public to protect human rights,promotehealthdiplomacy,and reducehealth References disparities. 1. American Nurses Association. Code of Ethics for Nurses with Provision 9: The profession of nursing, collectively InterpretiveStatements. Silver Spring,MD:Nursesbooks.org;2015. 2.MathesM,Reifsnyder J.Nurse’sLaw:LegalQuestions&Answers through its professional organizations, must articu- for thePracticingNurse. Indianoplois, IN: SigmaThetaTau Inter- late nursing values, maintain the integrity of the national;2014. profession, and integrate principles of social justice 3. Larson K, Elliott R. Understanding malpractice: a guide for into nursing and health policy.’’ (Code of Ethics for nephrology nurses.NephrolNurs J. 2009;36(4):375Y377. 1 4.Walke

    R.Elementsofnegligence andmalpractice.NursePract.

    Nurseswith Interpretive Statements, A

    NA, 2015, v) 2011;36(5):9Y11. Themostcommoncategoriesofnegligenceandnursing 5. Brock DM, Nicholson JG, Hooker RS. Physician assistant and errors in clinicalmanagement described in the literature nurse practitionermalpractice trends.MedCareResRev. 2016. 6,7 6. ReisingDL.Make your nursing caremalpractice-proof. include the following: American NurseToday.2012;7(1). 1. failure to follow standards of care, 7. TranDT, JohnsonM.Classifying nursing errors in BASIC


    of evidence that couldbeused at trial include Thereare4basicelementsofnegligence:(1) legaldutywas documentation in themedical recordof thepatient, any 2 owed, (2)breachofduty, (3)causation,and (4)damages. pertinent data collected frommedical tests on the pa- tient, and treatments received. Expert testimonials that Was a ‘‘LegalDuty’’Owed? could be used at trial can include from familymembers Legal duty is established by evaluating the registered of the patient, staff at the hospital, or clinic and hospital nurses’ (RNs’) scope of practice. A nurse’s legal duty administrators. ariseswhen the patient-nurse relationship is established; the RN orAPN accepts the patient assignment or agrees Causation,Did theNegligence Cause theHarm? to treat the patient and commences consultation or as- The third element in negligence is causation. The RN or 2 sessment. The duty of the RN or APN then involves APN provided nursing care thatwas below the standard ensuring that the treatment rendered or deliveredwould of care expected and harm resulted, a direct link. If an meet the standard of care expected. The question that is event occurred between the failure tomeet the standard answered for this element is concerning if a prudent or of care and theharm that resulted, then theremaynotbe reasonable RN or APN faced with the same situation a causal link that can be established. Provision 3 of the would have acted in the same manner. The policies Code of Ethics provides validation that the nurse must and procedures that the RN or APN practices under are protect the rights, health, and safety of the patient at 1 used todetermine if a legalduty isowed to thepatient. It all times. is essential that all RNs and APNs know and operate within the policies and procedures of the organization/ Damages hospital/unit that they are employed andpracticewithin. The fourth element in negligence is damages,which re-

    2 ForRNs andAPNswhomayhavemore than1employer, fers to themoney

    value of the harm. Once negligence careful attention is needed to ensure that they are aware hasbeenestablished, thepatientharmedmaybeawarded of their scopeofpractice and thepolicies andprocedures damages. foreachposition.Forexample, ifanAPN isemployedasan APN in

    1 organization but chooses towork in another in Professional

    Accountability apart-timeor inanon-callpositionasanRN,he/sheneeds TheRNandAPNcanprotect themselves frombeingnamed tobe careful that theyworkwithin their scopeofpractice in a lawsuitby adhering to the following statements: respectively. Theymust also know the scope of practice 1.Know the scopeofpractice forRNsorAPNsas stated when delegating tasks to othermembers of an interdisci- by the governingbodywithin the state. plinary team. For example, an RN can delegate tasks but 2.Alwayspracticewithin the confinementsof thepol- not assessmentof apatient.F


    icies and procedures of the organization. tiveauthority, thesearenotactsofdelegationbecauseboth 3.Maintaincompetency in thespecialtyareaofpractice. theAPNprescribingand theRNadministering themedica-

    4. Know legal principles and incorporate them into tion are responsible and accountable for their actions. everyday practice. Provision 4 of the Code of Ethics describes the authority,

    5. Acknowledge strengths andweaknessesofpractice.

    1 accountability,

    and responsibility for nursing practice. 6.Remain current in knowledge of the common diag- Boards of registered nursing, national regulatory stan- noses in the practice area. dards and professional organizational standards are 7.Maintain open and honest communicationwithpa- also referenced in cases of negligence. A practicing RN tients and their families. or APN should be involved in their local and national 8. Be accountable at all times. professionalorganizations to keepup todateon chang- TheANACodeofEthics fornursesestablishes theethical 1 ing scopes ofpractice. Provision 5 of theCode of Ethics standard for theprofession. TheRN andAPNmust follow furthervalidates theneed for theRN tomaintain compe- the 9 provisions in the Code of Ethics forNurses in their tence and continue to ensure growth on both personal everydaypractice toprotect themselvesand theirpatients.

    1 andprofessional levels. The 9provisionsof theCodeofEthics forNurses are ‘‘Provision

    1: The nurse practices with compassion Breach of LegalDuty and respect for the inherentdignity,worth,andunique The second element of negligence is determined after attributesof everyperson. the first element ismet. The court decides if there has Provision

    2: The nurse’s primary commitment is to been a breach of duty in cases of negligence. The deter- the patient whether an individual, family, group, minant taken into consideration is could itbe anticipated community, or population. that the injurywould occur from the act that took place Provision

    3:The nursepromotes, advocates for, and

    4, or omission of an act that should have taken place. protects the rights, health, and safety of the patient. 184 www.cns-journal.com July/August 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.clinicalmanage-

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