Leadership Week 3 Chapter 4

Read Chapter 4

1-which of the following behaviors may be (1) ethical but illegal, (2) legal but unethical, (3) illegal and unethical, and (4) legal and ethical.

A. Working in a clinic that performs abortions

b. Respecting the wishes of a client suffering from ALS that he be permitted to die with dignity and not placed on “breathing machines”

c. Respecting the health surrogate’s wishes regarding termination of life support of her friend

d. Observing a coworker take out two tablets of oxycodone as ordered for pain management for his patient but keeping one for himself, administering only one tablet to the patient.

2-differentiate among the following: deontological theories, utilitarianism, and principlism.

3-what do you think about health-care professionals disclosing information to clients about a poor prognosis, even though the information may cause severe distress.

4-What do they think about health-care professionals disclosing information to clients against family wishes?

5. You see a colleague use another nurse’s password to access the medication administration system and take out a narcotic. What would you do?

6.Your colleague’s child fell and was brought to the emergency department. She comes back up to the unit and tells you that they cleaned and debrided the wound, and she needs to change the dressings twice a day using a wet to dry method. You see her go into the supply system and remove the dressings and saline using a patient’s identification number. What would you do?

7. You are caring for a patient who has a terminal disease. He asks you if he is dying. Would you tell him? If yes, how? If no, what might you say? .

8-You are administering hydromorphone to a patient. The patient asks you what you are administering. Would you tell the patient about the medication?

APA style including presentation page and references page. INCLUDE IN TEXT CITATIONS

Plagiarism FREE

 Sally A. Weiss and Ruth M. Tappen • • •

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. Essentials of Nursing Leadership and Management

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Essentials of Nursing Leadership and Management

SIXTH EDITION

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Essentials of Nursing Leadership and Management

SIXTH EDITION

Sally A. Weiss, MSN, EdD, RN, CNE, ANEF Professor of Nursing

Nova Southeastern University Nursing Department Fort Lauderdale, Florida

Ruth M. Tappen, EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor

Florida Atlantic University College of Nursing Boca Raton, Florida

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2015 by F. A. Davis Company Copyright © 2015, 2010, 2007, 2004, 2001, 1998 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor, Nursing: Megan Klim Developmental Editor: Laurie Sparks Director of Content Development: Darlene D. Pedersen Content Project Manager: Echo Gerhart Electronic Project Editor: Katherine Crowley Design and Illustration Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treat- ments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from appli- cation of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infre- quently ordered drugs. Library of Congress Control Number: 2014945714 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rose- wood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Report- ing Service is: 978-0-8036-3663-7/15 0 + $.25.

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v

Dedication

To my granddaughter Sydni and my grandson Logan, who remind me how important it is to nurture our young nurses

and help them learn and grow. —SALLY A. WEISS

To students, colleagues, family, and friends, who have taught me so much about leadership.

—RUTH M. TAPPEN

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Preface

We are delighted to bring our readers this Sixth Edition of Essentials of Nursing Leadership and Management. This new edition has been updated to reflect the dynamic health care environment, safety initiatives, and changes in nursing practice. As in our previous editions, the content, examples, and diagrams were designed with the goal of assisting the new graduate to make the transition to professional nursing practice.

The Sixth Edition of Essentials of Nursing Leadership and Management focuses on the necessary knowledge and skills needed by the staff nurse as an integral member of the interprofessional health- care team and manager of patient care. Issues related to setting priorities, delegation, quality improve- ment, legal parameters of nursing practice, and ethical issues are updated for this edition.

This edition focuses on the current quality and safety issues and initiatives impacting the current health-care environment. We continue to bring you comprehensive, practical information on develop- ing a nursing career. Updated information on leading, managing, followership, and workplace issues continue to be included.

Essentials of Nursing Leadership and Management provides a strong foundation for the beginning nurse leader. We would like to thank the people at F. A. Davis for their assistance and our contribu- tors, reviewers, and students for their guidance and support.

—SALLY A. WEISS —RUTH M. TAPPEN

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Contributor PATRICIA BRADLEY, MED, PHD, RN Coordinator, Internationally Educated Nurses Program Faculty, Nursing Department York University Toronto, Ontario, Canada

Reviewers

WENDY GREENSPAN, MSN, RN, CCRN, CNE Assistant Professor Rockland Community College Suffem, New York

PAULA HOPPER, MSN, RN, CNE Professor of Nursing Jackson Community College Jackson, Mississippi

CLAIRE MEGGS, MSN, RN Associate Professor Lincoln Memorial University Harrogate, Tennessee

LUISE SPEAKMAN, PHD, RN Adjunct Faculty, Nursing Cape Cod Community College West Barnstable, Massachusetts

JENNIFER SUGG, RN, BSN, MSN, CCRN Nursing Instructor Wayne Community College Goldsboro, North Carolina

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Table of Contents

unit 1 Professional Considerations 1 chapter 1 Leadership and Followership 3 chapter 2 Manager 17 chapter 3 Nursing Practice and the Law 27 chapter 4 Questions of Values and Ethics 49

unit 2 Working Within an Organization 69 chapter 5 Organizations, Power, and Empowerment 71 chapter 6 Communicating With Others and Working

With the Interprofessional Team 87 chapter 7 Delegation and Prioritization of Client Care 103 chapter 8 Dealing With Problems and Conflict 121 chapter 9 People and the Process of Change 133

unit 3 Career Considerations 145 chapter 10 Issues of Quality and Safety 147 chapter 11 Promoting a Healthy Work Environment 173

unit 4 Professional Issues 203 chapter 12 Your Nursing Career 205 chapter 13 Evolution of Nursing as a Profession 225 chapter 14 Looking to the Future 235

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xii ■ Table of Contents

Appendices appendix 1 Codes of Ethics for Nurses 247

American Nurses Association Code of Ethics for Nurses Canadian Nurse Association Code of Ethics for Registered Nurses The International Council of Nurses Code of Ethics for Nurses

appendix 2 Standards Published by the American Nurses Association 249

appendix 3 Guidelines for the Registered Nurse in Giving, Accepting, or Rejecting a Work Assignment 251

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unit 1 Professional Considerations

chapter 1 Leadership and Followership

chapter 2 Manager

chapter 3 Nursing Practice and the Law

chapter 4 Questions of Values and Ethics

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chapter 1 Leadership and Followership

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the terms leadership and followership. ■ Discuss the importance of effective leadership and

followership for the new nurse. ■ Discuss the qualities and behaviors that contribute to

effective leadership. ■ Discuss the qualities and behaviors that contribute to

effective followership. OUTLINE Leadership Are You Ready to Be a Leader? Leadership Defined What Makes a Person a Leader? Leadership Theories

Trait Theories Behavioral Theories

Task Versus Relationship Motivation Theories Emotional Intelligence Situational Theories Transformational Leadership Moral Leadership Caring Leadership

Qualities of an Effective Leader Behaviors of an Effective Leader Followership Followership Defined Becoming a Better Follower Managing Up Conclusion

Nurses study leadership to learn how to work well with other people. We work with an extraordinary variety of people: technicians, aides, unit managers, housekeepers, patients, patients’ families, physi- cians, respiratory therapists, physical therapists, social workers, psychologists, and more. In this chapter, the most prominent leadership theories are introduced. Then, the characteristics and behaviors that can make you, a new nurse, an effective leader and follower are discussed.

Leadership

Are You Ready to Be a Leader? You may be thinking, “I’m just beginning my career in nursing. How can I be expected to be a leader now?” This is an important question. You will need time to refine your clinical skills and learn how to function in a new environment. But you can begin to assume some leadership functions right away within your new nursing roles. In fact, leadership should be seen as a dimension of nursing practice (Scott & Miles, 2013). Consider the following example:

Billie Thomas was a new staff nurse at Green Valley Nursing Care Center. After orientation, she was assigned to a rehabilitation unit with high ad- mission and discharge rates. Billie noticed that admissions and discharges were assigned rather hap- hazardly. Anyone who was “free” at the moment was directed to handle them. Sometimes, unlicensed as- sistant personnel were directed to admit or discharge residents. Billie believed that this was inappropriate because they are not prepared to do assessments and they had no preparation for discharge planning.

Billie had an idea how discharge planning could be improved but was not sure that she should bring it up because she was so new. “Maybe they’ve already thought of this,” she said to a former classmate. They began to talk about what they had learned in their leadership course before graduation. “I just keep hearing our instructor saying, ‘There’s only one manager, but anyone can be a leader.’ ”

“If you want to be a leader, you have to act on your idea. Why don’t you talk with your nurse manager?” her friend asked.

“Maybe I will,” Billie replied. Billie decided to speak with her nurse manager,

an experienced rehabilitation nurse who seemed not

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only approachable but also open to new ideas. “I have been so busy getting our new electronic health record system on line before the surveyors come that I wasn’t paying attention to that,” the nurse manager told her. “I’m glad you brought it to my attention.”

Billie’s nurse manager raised the issue at the next executive meeting, giving credit to Billie for having brought it to her attention. The other nurse manag- ers had the same response. “We were so focused on the new electronic health record system that we overlooked that. We need to take care of this situa- tion as soon as possible. Billie Thomas has leadership potential.”

Leadership Defined Successful nurse leaders are those who engage others to work together effectively in pursuit of a shared goal. Examples of shared goals in nursing would be providing excellent care, reducing infec- tion rates, designing cost-saving procedures, or challenging the ethics of a new policy.

Leadership is a much broader concept than is management. Although managers need to be leaders, management itself is focused specifically on achievement of organizational goals. Leadership, on the other hand:

. . . occurs whenever one person attempts to influence the behavior of an individual or group—up, down, or sideways in the organization—regardless of the reason. It may be for personal goals or for the goals of others, and these goals may or may not be congru- ent with organizational goals. Leadership is influ- ence (Hersey & Campbell, 2004, p. 12).

In order to lead, one must develop three important competencies: (1) diagnose: ability to understand the situation you want to influence, (2) adapt: make changes that will close the gap between the current situation and what you are hoping to achieve, and (3) communicate. No matter how much you diag- nose or adapt, if you cannot communicate effec- tively, you will probably not meet your goal (Hersey & Campbell, 2004).

What Makes a Person a Leader?

Leadership Theories There are many different ideas about how a person becomes a good leader. Despite years of research on this subject, no one idea has emerged as the clear

winner. The reason for this may be that different qualities and behaviors are most important in dif- ferent situations. In nursing, for example, some situations require quick thinking and fast action. Others require time to figure out the best solution to a complicated problem. Different leadership qualities and behaviors are needed in these two instances. The result is that there is not yet a single best answer to the question, “What makes a person a leader?”

Consider some of the best-known leadership theories and the many qualities and behaviors that have been identified as those of the effective nurse leader (Pavitt, 1999; Tappen, 2001):

Trait Theories At one time or another, you have probably heard someone say, “She’s a born leader.” Many believe that some people are natural leaders, while others are not. It is true that leadership may come more easily to some than to others, but everyone can be a leader, given the necessary knowledge and skill.

An important 5-year study of 90 outstanding leaders by Warren Bennis published in 1984 identi- fied four common traits. These traits hold true today:

1. Management of attention. These leaders communicated a sense of goal direction that attracted followers.

2. Management of meaning. These leaders created and communicated meaning and purpose.

3. Management of trust. These leaders demonstrated reliability and consistency.

4. Management of self. These leaders knew themselves well and worked within their strengths and weaknesses (Bennis, 1984).

Behavioral Theories The behavioral theories focus on what the leader does. One of the most influential behavioral theo- ries is concerned with leadership style (White & Lippitt, 1960) (Table 1-1).

The three styles are:

1. Autocratic leadership (also called directive, controlling, or authoritarian). The autocratic leader gives orders and makes decisions for the group. For example, when a decision needs to be made, an autocratic leader says, “I’ve decided that this is the way we’re going to solve our

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chapter 1 ■ Leadership and Followership 5

problem.” Although this is an efficient way to run things, it squelches creativity and may reduce team member motivation.

2. Democratic leadership (also called participative). Democratic leaders share leadership. Important plans and decisions are made with the team (Chrispeels, 2004). Although this appears to be a less efficient way to run things, it is more flexible and usually increases motivation and creativity. In fact, involving team members, giving them “permission to think, speak and act” brings out the best in them and makes them more productive, not less (Wiseman & McKeown, 2010, p. 3). Decisions may take longer to make, but once made everyone supports them (Buchanan, 2011).

3. Laissez-faire leadership (also called permissive or nondirective). The laissez-faire (“let someone do”) leader does very little planning or decision making and fails to encourage others to do it. It is really a lack of leadership. For example, when a decision needs to be made, a laissez- faire leader may postpone making the decision or never make the decision at all. In most instances, the laissez-faire leader leaves people feeling confused and frustrated because there is no goal, no guidance, and no direction. Some mature, self-motivated individuals thrive under laissez-faire leadership because they need little direction. Most people, however, flounder under this kind of leadership.

Pavitt summed up the differences among these three styles: a democratic leader tries to move the group toward its goals; an autocratic leader tries to move the group toward the leader’s goals; and a

laissez-faire leader makes no attempt to move the group (1999, pp. 330ff ).

Task Versus Relationship Another important distinction is between a task focus and a relationship focus (Blake, Mouton, & Tapper, 1981). Some nurses emphasize the tasks (e.g., administering medication, completing patient records) and fail to recognize that interpersonal relationships (e.g., attitude of physicians toward nursing staff, treatment of housekeeping staff by nurses) affect the morale and productivity of employees. Others focus on the interpersonal aspects and ignore the quality of the job being done as long as people get along with each other. The most effective leader is able to balance the two, attending to both the task and the relationship aspects of working together.

Motivation Theories The concept of motivation seems simple: we will act to get what we want but avoid whatever we don’t want to do. However, motivation is still sur- rounded in mystery. The study of motivation as a focus of leadership began in the 1920s with the historic Hawthorne studies. Several experi- ments were conducted to see if increasing light and, later, improving other working conditions would increase the productivity of workers in the Haw- thorne, Illinois, electrical plant. This proved to be true, but then something curious happened: when the improvements were taken away, the workers continued to show increased productivity. The researchers concluded that the explanation was found not in the conditions of the experiments but in the attention given to the workers by the experimenters.

table 1-1

Comparison of Autocratic, Democratic, and Laissez-Faire Leadership Styles Autocratic Democratic Laissez-Faire

Amount of freedom Little freedom Moderate freedom Much freedom Amount of control High control Moderate control Little control Decision making By the leader Leader and group together By the group or by no one Leader activity level High High Minimal Assumption of responsibility Leader Shared Abdicated Output of the group High quantity, good quality Creative, high quality Variable, may be poor quality Efficiency Very efficient Less efficient than autocratic style Inefficient

Source: Adapted from White, R.K., & Lippitt, R. (1960). Autocracy and democracy: An experimental inquiry. New York: Harper & Row.

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Frederick Herzberg and David McClelland also studied factors that motivated workers in the work- place. Their findings are similar to the elements in Maslow’s Hierarchy of Needs. Table 1-2 summa- rizes these three historical motivation theories that continue to be used by leaders today (Herzberg, 1966; Herzberg, Mausner, & Snyderman, 1959; Maslow, 1970; McClelland, 1961).

Emotional Intelligence The relationship aspects of leadership are also the focus of the work on emotional intelligence and leadership (Goleman, Boyatzes, & McKee, 2002). From the perspective of emotional intelligence, what distinguishes ordinary leaders from leadership “stars” is that the “stars” are consciously addressing the effect of people’s feelings on the team’s emo- tional reality.

How is this done? First, the emotionally intel- ligent leader recognizes and understands his or her own emotions. When a crisis occurs, he or she is able to manage them, channel them, stay calm and clearheaded, and suspend judgment until all the facts are in (Baggett & Baggett, 2005).

Second, the emotionally intelligent leader welcomes constructive criticism, asks for help when needed, can juggle multiple demands with- out losing focus, and can turn problems into opportunities.

Third, the emotionally intelligent leader listens attentively to others, recognizes unspoken concerns, acknowledges others’ perspectives, and brings people together in an atmosphere of respect, coop- eration, collegiality, and helpfulness so they can direct their energies toward achieving the team’s goals. “The enthusiastic, caring, and supportive leader generates those same feelings throughout the team,” wrote Porter-O’Grady of the emotionally intelligent leader (2003, p. 109).

Situational Theories People and leadership situations are far more complex than the early theories recognized. Situa- tions can also change rapidly, requiring more complex theories to explain leadership (Bennis, Spreitzer, & Cummings, 2001).

Instead of assuming that one particular approach works in all situations, situational theories recog- nize the complexity of work situations and encour- age the leader to consider many factors when deciding what action to take. Adaptability is the key to the situational approach (McNichol, 2000).

Situational theories emphasize the importance of understanding all the factors that affect a par- ticular group of people in a particular environment. The most well-known is the Situational Leader- ship Model by Dr. Paul Hersey. The appeal of this model is that it focuses on the task and the follower.

table 1-2

Leading Motivation Theories Theory Summary of Motivation Requirements

Maslow, 1954 Categories of Need: Lower needs (listed first below) must be fulfilled before others are activated. Physiological Safety Belongingness Esteem Self-actualization

Herzberg, 1959 Two factors that influence motivation. The absence of hygiene factors can create job dissatisfaction, but their presence does not motivate or increase satisfaction.

1. Hygiene factors: Company policy, supervision, interpersonal relations, working conditions, salary 2. Motivators: Achievement, recognition, the work itself, responsibility, advancement

McClelland, 1961

Motivation results from three dominant needs. Usually all three needs are present in each individual but vary in importance depending on the position a person has in the workplace. Needs are also shaped over time by culture and experience.

1. Need for achievement: Performing tasks on a challenging and high level 2. Need for affiliation: Good relationships with others 3. Need for power: Being in charge

Source: Adapted from Hersey, P., & Campbell, R. (2004). Leadership: A behavioral science approach. Calif.: Leadership Studies Publishing.

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chapter 1 ■ Leadership and Followership 7 The key is to marry the readiness of the follower with the tasks at hand. “Readiness is defined as the extent to which a follower demonstrates the ability and willingness to accomplish a specific task” (Hersey & Campbell, 2004, p. 114). “The leader needs to spell out the duties and responsibilities of the individual and the group” (Hersey & Campbell, 2004).

Followers’ readiness levels can range from unable, unwilling, and insecure to able, willing, and confi- dent. The leader’s behavior will focus on appropri- ately fulfilling the followers’ needs, which are identified by their readiness level and the task. Leader behaviors will range from telling, guid- ing, and directing to delegating, observing, and monitoring.

Where did you fall in this model during your first clinical rotation? Compare this with where you are now. In the beginning, the clinical instructor gave you clear instructions, closely guiding and directing you. Now, she or he is most likely delegat- ing, observing, and monitoring. As you move into your first nursing position, you may return to the needing, guiding, and directing stage. But, you may soon become a leader/instructor for new nursing students, guiding and directing them.

Transformational Leadership Although the situational theories were an improve- ment over earlier theories, there was still something missing. Meaning, inspiration, and vision were not given enough attention (Tappen, 2001). These are the distinguishing features of transformational leadership.

The transformational theory of leadership emphasizes that people need a sense of mission that goes beyond good interpersonal relationships or an appropriate reward for a job well done (Bass & Avolio, 1993). This is especially true in nursing. Caring for people, sick or well, is the goal of the profession. Most people chose nursing in order to do something for the good of humankind; this is their vision. One responsibility of nursing leader- ship is to help nurses see how their work helps them achieve their vision.

Transformational leaders can communicate their vision in a manner that is so meaningful and excit- ing that it reduces negativity (Leach, 2005) and inspires commitment in the people with whom they work (Trofino, 1995). Dr. Martin Luther King Jr. had a vision for America: “I have a dream that

one day my children will be judged by the content of their character, not the color of their skin” (quoted by Blanchard & Miller, 2007, p. 1). A great leader shares his or her vision with his followers. You can do the same with your colleagues and team. If suc- cessful, the goals of the leader and staff will “become fused, creating unity, wholeness, and a collective purpose” (Barker, 1992, p. 42). See Box 1-1 for an example of a leader with visionary goals.

Moral Leadership A series of highly publicized corporate scandals redirected attention to the values and ethics that underlie the practice of leadership as well as that of patient care (Dantley, 2005). Moral leadership involves deciding how one ought to remain honest, fair, and socially responsible (Bjarnason & LaSala, 2011) under any circumstances. Caring about one’s patients and the people who work for you as people as well as employees (Spears & Lawrence, 2004) is part of moral leadership. This can be a great chal- lenge in times of limited financial resources.

Molly Benedict was a team leader on the acute geri- atric unit (AGU) when a question of moral leader- ship arose. Faced with large budget cuts in the middle of the year and feeling a little desperate to f igure out how to run the AGU with fewer staff, her nurse manager suggested that reducing the time that unlicensed assistive personnel (UAP) spent ambulating patients would enable UAPs to care for 15 patients, up from the current 10 per UAP.

This is leadership on the very grandest scale. BHAGs are Big, Hairy, Audacious Goals. Coined by Jim Collins, BHAGs are big ideas, visions for the future. Here is an example: Gigi Mander, originally from the Philippines, dreams of buying hundreds of acres of farmland for peasant families in Asia or Africa. She would install irrigation systems, provide seed and modern farming equipment, and help them market their crops. This is not just a dream, however; she has a business plan for her BHAG and is actively seeking investors. Imagination, creativity, planning, persistence, audacity, courage: these are all needed to put a BHAG into practice. Do you have a BHAG? How would you make it real?

box 1-1

BHAGs, Anyone?

Adapted from Buchanan, L. (2012). The world needs big ideas. INC Magazine, 34(9), 57–58.

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“George,” responded Molly, “you know that inactiv- ity has many harmful effects, from emboli to disori- entation, in our very elderly population. Let’s try to f igure out how to encourage more self-care and even family involvement in care so the UAPs can still have time to walk patients and prevent their becom- ing nonambulatory.”

Molly based her action on important values, par- ticularly those of providing the highest quality care possible. Stewart and colleagues (2012) urge that caring not be sacrificed at the altar of efficiency (p. 227). This example illustrates how great a chal- lenge that can be for today’s nurse leaders. The American Nurses Association Code of Ethics (2001) provides the moral compass for nursing practice and leadership (ANA, 2001; Bjarnason & LaSala, 2011).

Box 1-2 summarizes a contemporary list of 13 distinctive leadership styles, most of which match up to the eight theories just discussed.

Caring Leadership Caring leadership in nursing comes from two primary sources: servant leadership and emotional

intelligence in the management literature, and caring as a foundational value in nursing (Green- leaf, 2008; McMurry, 2012; Rhodes, Morris, & Lazenby, 2011; Spears, 2010). While it is uniquely suited to nursing leadership, it is hard to imagine any situation in which an uncaring leader would be preferred over a caring leader.

Servant-leaders choose to serve first and lead second, making sure that people’s needs within the work setting are met (Greenleaf, 2008). Emotion- ally intelligent leaders are especially aware of not only their own feelings but others’ feelings as well (see Box 1-1). Combining these leadership and management theories and the philosophy of caring in nursing, you can see that caring leadership is fundamentally people-oriented. The following are the characteristics and behaviors of caring leaders:

■ They respect their coworkers as individuals. ■ They listen to other people’s opinions and

preferences, giving them full consideration. ■ They maintain awareness of their own and

others’ feelings. ■ They empathize with others, understanding

their needs and concerns. ■ They develop their own and their team’s

capacities. ■ They are competent, both in leadership and in

clinical practice. This includes both knowledge and skill in leadership and clinical practice.

As you can see, caring leadership cuts across the leadership theories discussed so far and encom- passes some of their best features. An authoritarian leader, for example, can be as caring as a democratic leader (Dorn, 2011). Caring leadership is attractive to many nurses because it applies many of the prin- ciples of working with patients and working with nursing staff to the interdisciplinary team.

Qualities of an Effective Leader If leadership is seen as the ability to influence, what qualities must the leader possess in order to be able to do that? Integrity, courage, positive attitude, ini- tiative, energy, optimism, perseverance, generosity, balance, ability to handle stress, and self-awareness are some of the qualities of effective leaders in nursing (Fig. 1.1):

■ Integrity. Integrity is expected of health-care professionals. Patients, colleagues, and

1. Adaptive: flexible, willing to change and devise new approaches.

2. Emotionally Intelligent: aware of his/her own and others’ feelings.

3. Charismatic: magnetic personalities who attract people to follow them.

4. Authentic: demonstrates integrity, character, and honesty in relating to others.

5. Level 5: ferociously pursues goals but gives credit to others and takes responsibility for his/her mistakes.

6. Mindful: thoughtful, analytic, and open to new ideas. 7. Narcissistic: doesn’t listen to others and doesn’t

tolerate disagreement but may have a compelling vision.

8. No Excuse: mentally tough, emphasizes accountability and decisiveness.

9. Resonant: motivates others through their energy and enthusiasm.

10. Servant: “empathic, aware and healing,” (p. 76) leads to serve others.

11. Storyteller: uses stories to convey messages in a memorable, motivating fashion.

12. Strength-Based: focuses and capitalizes on his/her own and others’ talents.

13. Tribal: build a common culture with strong sharing of values and beliefs.

box 1-2

Distinctive Styles of Leadership

Adapted from Buchanan, L. (2012/June). 13 ways of looking at a leader. INC Magazine, 74–76.

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chapter 1 ■ Leadership and Followership 9

employers all expect nurses to be honest, law-abiding, and trustworthy. Adherence to both a code of personal ethics and a code of professional ethics (Appendix 1, American Nurses Association Code of Ethics for Nurses) is expected of every nurse. Would-be leaders who do not exhibit these characteristics cannot expect them of their followers. This is an essential component of moral leadership.

■ Courage. Sometimes, being a leader means taking some risks. In the story of Billie Thomas, for example, Billie needed some courage to speak to her nurse manager about a problem she had observed.

■ Positive attitude. A positive attitude goes a long way in making a good leader. In fact, many outstanding leaders cite negative attitude as the single most important reason for not hiring someone (Maxwell, 1993, p. 98). Sometimes a leader’s attitude is noticed by followers more quickly than are the leader’s actions.

■ Initiative. Good ideas are not enough. To be a leader, you must act on those good ideas. No one will make you do this; this requires initiative on your part.

■ Energy. Leadership requires energy. Both leadership and followership are hard but satisfying endeavors that require effort. It

is also important that the energy be used wisely.

■ Optimism. When the work is difficult and one crisis seems to follow another in rapid succession, it is easy to become discouraged. It is important not to let discouragement keep you and your coworkers from seeking ways to resolve the problems. In fact, the ability to see a problem as an opportunity is part of the optimism that makes a person an effective leader. Like energy, optimism is “catching.” Holman (1995) called this being a winner instead of a whiner (Table 1-3).

■ Perseverance. Effective leaders do not give up easily. Instead, they persist, continuing their efforts when others are tempted to stop trying. This persistence often pays off.

■ Generosity. Freely sharing your time, interest, and assistance with your colleagues is a trait of a generous leader. Sharing credit for successes and support when needed are other ways to be a generous leader (Buchanan, 2013; Disch, 2013).

■ Balance. In the effort to become the best nurses they can be, some nurses may forget that other aspects of life are equally important. As important as patients and colleagues are, family and friends are important, too. Although school and work are meaningful activities, cultural, social, recreational, and spiritual activities also have meaning. You need to find a balance between work and play.

■ Ability to handle stress. There is some stress in almost every job. Coping with stress in as positive and healthy a manner as possible helps to conserve energy and can be a model for

Qualities

Behaviors

Integrity

Courage

Initiative

Energy

Optimism

Perseverance

Balance

Ability to handle stress

Self-awareness

Think critically

Solve problems

Communicate skillfully

Set goals, share vision

Develop self and others

Figure 1.1 Keys to effective leadership.

table 1-3

Winner or Whiner—Which Are You? A winner says: A whiner says:

“We have a real challenge here.”

“This is really a problem.”

“I’ll give it my best.” “Do I have to?” “That’s great!” “That’s nice, I guess.” “We can do it!” “That will never succeed.” “Yes!” “Maybe . . .”

Source: Adapted from Holman, L. (1995). Eleven lessons in self- leadership: Insights for personal and professional success. Lexington, Ky.: A Lesson in Leadership Book.

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Rocio Quintana

10 unit 1 ■ Professional Considerations

others. Maintaining balance and handling stress are reviewed in Chapter 11.

■ Self-awareness. How sharp is your emotional intelligence? People who do not understand themselves are limited in their ability to understand people with whom they are working. They are far more likely to fool themselves than are self-aware people. For example, it is much easier to be fair with a coworker you like than with one you do not like. Recognizing that you like some people more than others is the first step in avoiding unfair treatment based on personal likes and dislikes.

Behaviors of an Effective Leader Leadership requires action. The effective leader chooses the action carefully. Important leadership behaviors include setting priorities, thinking criti- cally, solving problems, respecting people, commu- nicating skillfully, communicating a vision for the future, and developing oneself and others.

■ Setting priorities. Whether planning care for a group of patients or creating a strategic plan for an organization, priorities continually shift and demand your attention. As a leader you will need to remember the three E’s of prioritization: evaluate, eliminate, and estimate. Continually evaluate what you need to do, eliminate tasks that someone else can do, and estimate how long your top priorities will take you to complete.

■ Thinking critically. Critical thinking is the careful, deliberate use of reasoned analysis to reach a decision about what to believe or what to do (Feldman, 2002). The essence of critical thinking is a willingness to ask questions and to be open to new ideas or new ways to do things. To avoid falling prey to assumptions and biases of your own or others, ask yourself frequently, “Do I have the information I need? Is it accurate? Am I prejudging a situation?” ( Jackson, Ignatavicius, & Case, 2004).

■ Solving problems. Patient problems, paperwork problems, staff problems: these and others occur frequently and need to be solved. The effective leader helps people identify problems and work through the problem- solving process to find a reasonable solution.

■ Respecting and valuing the individual. Although people have much in common, each individual has different wants and needs and has had different life experiences. For example, some people really value the psychological rewards of helping others; other people are more concerned about earning a decent salary. There is nothing wrong with either of these points of view; they are simply different. The effective leader recognizes these differences in people and helps them find the rewards in their work that mean the most to them.

■ Skillful communication. This includes listening to others, encouraging exchange of information, and providing feedback: 1. Listening to others. Listening is separate

from talking with other people; listening involves both giving and receiving information. The only way to find out people’s individual wants and needs is to watch what they do and to listen to what they say. It is amazing how often leaders fail simply because they did not listen to what other people were trying to tell them.

2. Encouraging exchange of information. Many misunderstandings and mistakes occur because people fail to share enough information with each other. The leader’s role is to make sure that the channels of communication remain open and that people use them.

3. Providing feedback. Everyone needs some information about the effectiveness of their performance. Frequent feedback, both positive and negative, is needed so people can continually improve their performance. Some nurse leaders find it difficult to give negative feedback because they fear that they will upset the other person. How else can the person know where improvement is needed? Negative feedback can be given in a manner that is neither hurtful nor resented by the individual receiving it. In fact, it is often appreciated. Other nurse leaders, however, fail to give positive feedback, assuming that coworkers will know when they are doing a good job. This is also a mistake because everyone appreciates positive feedback. In fact, for some people, it is the most important reward they get from their jobs.

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chapter 1 ■ Leadership and Followership 11 ■ Communicating a vision for the future. The

effective leader has a vision for the future. Communicating this vision to the group and involving everyone in working toward that vision generate the inspiration that keeps people going when things become difficult. Even better, involving people in creating the vision is not only more satisfying for employees but also has the potential to produce the most creative and innovative outcomes (Kerfott, 2000). It is this vision that helps make work meaningful.

■ Developing oneself and others. Learning does not end upon leaving school. In fact, experienced nurses say that school is just the beginning, that school only prepares you to continue learning throughout your career. As new and better ways to care for patients are developed, it is your responsibility as a professional to critically analyze them and decide whether they would be better for your patients than current ones. Effective leaders not only continue to learn but also encourage others to do the same. Sometimes, leaders function as teachers. At other times, their role is primarily to encourage others to seek more knowledge.

Anderson, Manno, O’Connor, and Gallagher (2010) invited five nurse managers from Penn Presbyterian Medical Center who had received top ratings in leadership from their staff to participate in a focus group on successful leadership. They reported that visibility, communication, and the values of respect and empathy were the key elements of successful leadership. The authors quoted participants to illustrate each of these elements (p. 186):

Visibility: “I try to come in on the off shifts even for an hour or two just to have them see you.”

Communication: “Candid feedback” “A lot of rounding.” (Note: this could also be visibility.)

Respect and Empathy: “Do I expect you to take seven patients? No, because I wouldn’t be able to do it.” (punctuation adjusted).

These three key elements draw on components from several leadership qualities and behaviors: skillful communication, respecting and valuing the individual, and energy. Visibility is not as pro- minent in many of the leadership theories but

deserves a place in the description of what effective leaders do.

Followership

Followership and leadership are separate but com- plementary roles. The roles are also reciprocal: without followers, one cannot be a leader. One also cannot be a follower without having a leader (Lyons, 2002).

It is as important to be an effective follower as it is to be an effective leader. In fact, most of us are followers: members of a team, attendees at a meeting, staff of a nursing care unit, and so forth.

Followership Defined Followership is not a passive role. On the contrary, the most valuable follower is a skilled, self-directed professional, one who participates actively in deter- mining the group’s direction, invests his or her time and energy in the work of the group, thinks criti- cally, and advocates for new ideas (Grossman & Valiga, 2000).

Imagine working on a patient care unit where all staff members, from the unit secretary to the assistant nurse manager, willingly take on extra tasks without being asked (Spreitzer & Quinn, 2001), come back early from coffee breaks if they are needed, complete their charting on time, support ways to improve patient care, and are proud of the high-quality care they provide. Wouldn’t it be won- derful to be a part of that team?

Becoming a Better Follower There are a number of things you can do to become a better follower:

■ If you discover a problem, inform your team leader or manager right away.

■ Even better, include a suggestion for solving the problem in your report.

■ Freely invest your interest and energy in your work.

■ Be supportive of new ideas and new directions suggested by others.

■ When you disagree, explain why. ■ Listen carefully and reflect on what your leader

or manager says. ■ Continue to learn as much as you can about

your specialty area. ■ Share what you learn.

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12 unit 1 ■ Professional Considerations

Being an effective follower not only will make you a more valuable employee but will also increase the meaning and satisfaction that you get from your work.

Managing Up Most team leaders and nurse managers respond positively to having staff who are good followers. Occasionally, you will encounter a poor leader or manager who can confuse, frustrate, and even dis- tress you. Here are a few suggestions for handling this:

■ Avoid adopting the ineffective behaviors of this individual.

■ Continue to do your best work and to contribute leadership to the group.

■ If the situation worsens, enlist the support of others on your team to seek a remedy; do not try to do this alone as a new graduate.

■ If the situation becomes intolerable, consider the option of transferring to another unit or seeking another position (Deutschman, 2005; Korn, 2004).

There is still more a good follower can do. This is called managing up. Managing up is defined as “the process of consciously working with your boss to obtain the best possible results for you, your boss, and your organization” (Zuber & James quoted by Turk, 2007, p. 21). This is not a scheme to mani- pulate your manager or to get more rewards than you have earned. Instead, it is a guide for better understanding your manager, what he or she expects of you, and what your manager’s own needs might be.

Every manager has areas of strength and weak- ness. A good follower recognizes these and helps the manager capitalize on areas of strength and compensate for areas of weakness. For example, if your nurse manager is slow completing quality improvement reports, you can offer to help get them done. On the other hand, if your nurse manager seems to be especially skilled in defusing

conflicts between attending physicians and nursing staff, you can observe how he handles these situa- tions and ask him how he does it. Remember that your manager is human, a person with as many needs, concerns, distractions, and ambitions as anyone else. This will help you keep your expecta- tions of your manager realistic and reduce the dis- tance between you and your manager.

There are several other ways in which to manage up. U.S. Army General and former Secretary of State Colin Powell said, “You can’t make good deci- sions unless you have good information” (Powell, 2012, p. 42). Keep your manager informed. No one likes to be surprised, least of all a manager who finds that you have known about a problem (a nursing assistant who is spending too much time in the staff lounge, for example) and not brought it to her attention until it became critical. When you do bring a problem to your manager’s attention, try to have a solution to offer. This is not always possible, but when it is, it will be very much appreciated.

Finally, show your appreciation whenever pos- sible (Bing, 2010). Show respect for your manager’s authority and appreciation for what your manager does for the staff of your unit. Let others know of your appreciation, particularly those to whom your manager must answer.

Conclusion

To be an effective nurse, you need to be an effective leader. Your patients, peers, and employer are depending on you to lead. Successful leaders never stop learning and growing. John Maxwell (1998), an expert on leadership, wrote, “Who we are is who we attract” (p. xi). To attract leaders, people need to start leading and never stop learning to lead.

The key elements of leadership and followership have been discussed in this chapter. Many of the leadership and followership qualities and behaviors mentioned here are discussed in more detail in later chapters.

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chapter 1 ■ Leadership and Followership 13

Study Questions

1. Why is it important for nurses to be good leaders? What qualities have you observed from nurses that exemplify effective leadership in action? How do you think these behaviors might have improved the outcomes of their patients?

2. Why are effective followers as important as effective leaders? 3. Review the various leadership theories discussed in the chapter. Which ones especially apply to

leading in today’s health-care environment? Support your answer with specific examples. 4. Select an individual whose leadership skills you particularly admire. What are some qualities

and behaviors that this individual displays? How do these relate to the leadership theories discussed in this chapter? In what ways could you emulate this person?

5. As a new graduate, what leadership and followership skills will you work on developing during the first 3 months of your first nursing position? Why?

Case Study to Promote Critical Reasoning

Two new associate-degree graduate nurses were hired for the pediatric unit. Both worked three 12-hour shifts a week, Jan on the day-to-evening shift and Ronnie at night. Whenever their shifts overlapped, they would compare notes on their experience. Jan felt she was learning rapidly, gaining clinical skills, and beginning to feel at ease with her colleagues.

Ronnie, however, still felt unsure of herself and often isolated. “There have been times,” she told Jan, “that I am the only registered nurse on the unit all night. The aides and LPNs are really experienced, but that’s not enough. I wish I could work with an experienced nurse as you are doing.”

“Ronnie, you are not even finished with your 3-month orientation program,” said Jan. “You should never be left alone with all these sick children. Neither of us is ready for that kind of responsibility. And how will you get the experience you need with no experienced nurses to help you? You must speak to our nurse manager about this.”

“I know I should, but she’s so hard to reach. I’ve called several times, and she’s never available. She leaves all the shift assignments to her assistant. I’m not sure she even reviews the schedule before it’s posted.”

“You will have to try harder to reach her. Maybe you could stay past the end of your shift one morning and meet with her,” suggested Jan. “If something happens when you are the only nurse on the unit, you will be held responsible.” 1. In your own words, summarize the problem that Jan and Ronnie are discussing. To what extent

is this problem due to a failure to lead? Who has failed to act? 2. What style of leadership was displayed by Jan, Ronnie, and the nurse manager? How effective

was their leadership? Did Jan’s leadership differ from that of Ronnie and the nurse manager? In what way?

3. In what ways has Ronnie been an effective follower? In what ways has Ronnie not been so effective as a follower?

4. If an emergency occurred and was not handled well while Ronnie was the only nurse on the unit, who would be responsible? Explain why this person or persons would be responsible.

5. If you found yourself in Ronnie’s situation, what steps would you take to resolve the problem? Show how the leader characteristics and behaviors found in this chapter support your solution to the problem.

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14 unit 1 ■ Professional Considerations

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chapter 1 ■ Leadership and Followership 15 Leadership Using a Habermasian Lens. Collegian, 19, 223–229.

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chapter 2 Manager

OBJECTIVES After reading this chapter, the student should be able to: ■ Define the term management. ■ Distinguish scientific management and human relations–

based management. ■ Explain servant leadership. ■ Discuss the qualities and behaviors that contribute to

effective management. OUTLINE Management Are You Ready to Be a Manager? What Is Management?

Management Theories Scientific Management Human Relations–Based Management Servant Leadership Qualities of an Effective Manager Behaviors of an Effective Manager Interpersonal Activities Decisional Activities Informational Activities Conclusion

Every nurse needs to be a good leader and a good follower. In Chapter 1 we defined leadership and followership, and showed that even as a new nurse, you can be an effective leader. Not everyone needs to be a manager, however. New graduates are not ready to take on management responsibilities. Once you have had time to develop your clinical and leadership skills, then you can begin to think about taking on management responsibilities (Table 2-1).

Management

Are You Ready to Be a Manager? For most new nurses, the answer is no, you should not accept managerial responsibility. Your clinical skills are still underdeveloped. You need to direct your energies to building your own skills, including your leadership skills, before you begin supervising other people.

What Is Management? The essence of management is getting work done through others. The classic definition of manage- ment was Henri Fayol’s 1916 list of managerial tasks: planning, organizing, commanding, coordi- nating, and controlling the work of a group of employees (Wren, 1972). But Mintzberg (1989) argued that managers really do whatever is needed

to make sure that employees do their work and do it well. Lombardi (2001) added that two-thirds of a manager’s time is spent on people problems. The rest is taken up by budget work, going to meetings, preparing reports, and other administrative tasks.

Management Theories

There are two major but opposing schools of thought in management: scientific management and the human relations–based approach. As its name implies, the human-relations approach emphasizes the interpersonal aspects of managing people, whereas scientific management emphasizes the task aspects.

Scientific Management Almost 100 years ago, Frederick Taylor argued that most jobs could be done more efficiently if they were analyzed thoroughly (Lee, 1980; Locke, 1982). Given a well-designed task and enough incentive to get the work done, workers will be more produc- tive. For example, Taylor promoted the concept of paying people by the piece instead of by the hour. In health care, the equivalent of what Taylor recom- mended would be paying by the number of patients bathed or visited at home rather than by the number of hours worked. This creates an incentive to get

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18 unit 1 ■ Professional Considerations

the most work done in the least amount of time. Taylorism stresses that there is a best way to do a job, which is usually the fastest way to do the job as well (Dantley, 2005).

Work is analyzed to improve efficiency. In health care, for example, there has been much discussion about the time and effort it takes to bring a disabled patient to physical therapy versus sending the ther- apist to the patient’s home or inpatient unit. Reduc- ing staff or increasing the productivity of existing employees to save money is also based on this kind of thinking.

Nurse managers who use the principles of sci- entific management will pay particular attention to the types of assessments and treatments done on the unit, the equipment needed to do them effi- ciently, and the strategies that would facilitate more efficient accomplishment of these tasks. Typically, these nurse managers keep careful records of the amount of work accomplished and reward those who accomplish the most.

Human Relations–Based Management McGregor’s theories X and Y provide a good con- trast between scientific management and human relations–based management. Like Taylorism, Theory X reflects a common attitude among man- agers that most people do not want to work very hard and that the manager’s job is to make sure that they do work hard (McGregor, 1960). To accom- plish this, according to Theory X, a manager needs to employ strict rules, constant supervision, and the threat of punishment (reprimands, withheld raises, and threats of job loss) to create industrious, con- scientious workers.

Theory Y, which McGregor preferred, is the opposite viewpoint. Theory Y managers believe that the work itself can be motivating and that people will work hard if their managers provide a supportive environment. A Theory Y manager

emphasizes guidance rather than control, develop- ment rather than close supervision, and reward rather than punishment (Fig. 2.1). A Theory Y nurse manager is concerned with keeping employee morale as high as possible, assuming that satisfied, motivated employees will do the best work. Employ- ees’ attitudes, opinions, hopes, and fears are impor- tant to this type of nurse manager. Considerable effort is expended to work out conflicts and promote mutual understanding to provide an environment in which people can do their best work.

Servant Leadership The emphasis on people and interpersonal rela- tionships is taken one step further by Greenleaf (2004), who wrote an essay in 1970 that began the servant leadership movement. Like transforma- tional and caring leadership, servant leadership has a special appeal to nurses and other health-care

table 2-1

Differences Between Leadership and Management Leadership Management

Based on influence and shared meaning Based on authority An informal role A formally designated role An achieved position As assigned position Part of every nurse’s responsibility Usually responsible for budgets, appraising, hiring, and firing people Requires initiative and independent thinking Improved by the use of effective leadership skills

THEORY X

Work is something to be avoided

People want to do as little as possible

Use control-supervision-punishment

THEORY Y

The work itself can be motivating

People really want to do their job well

Use guidance-development-reward

Figure 2.1 Theory X versus Theory Y.

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chapter 2 ■ Manager 19 professionals. Despite its name, servant leadership applies more to people in supervisory or adminis- trative positions than to people in staff positions.

The servant leader–style manager believes that people have value as people, not just as workers (Spears & Lawrence, 2004). The manager is com- mitted to improving the way each employee is treated at work. The attitude is “employee first,” not “manager first.” So the manager sees himself or herself as being there for the employee. Here is an example:

Hope Marshall is a relatively new staff nurse at Jefferson County Hospital. When she was invited to be the staff nurse representative on the search com- mittee for a new chief nursing off icer, she was very excited about being on a committee with so many managerial and administrative people. As the interviews of candidates began, she focused on what they had to say. All the candidates had impressive résumés and spoke confidently about their accom- plishments. Hope was impressed but did not yet prefer one over the other. Then the f inal candidate spoke to the committee. “My primary job,” he said, “is to make it possible for each nurse to do the very best job he or she can do. I am here to make their work easier, to remove barriers, and to provide them with whatever they need to provide the best patient care possible.” Hope had never heard the term servant leadership, but she knew immediately that this candidate, who articulated the essence of servant leadership, was the one she would support for this important position.

Qualities of an Effective Manager

Two-thirds of people who leave their jobs say the main reason was an ineffective or incompetent manager (Hunter, 2004). A survey of 3,266 newly licensed nurses found that lack of support from their manager was the nurses’ primary reason for leaving their position, followed by a stressful work environment. Following are some of the indicators of their stressful work environment:

■ 25% reported at least one needle stick in their first year.

■ 39% reported at least one strain or sprain. ■ 62% reported experiencing verbal abuse. ■ 25% reported a shortage of supplies needed to

do their work.

These results underscore the importance of having effective nurse managers who can create an envi- ronment in which new nurses thrive (Kovner, Brewer, Fairchild, et al., 2007).

Nurse managers hold pivotal positions in hospi- tals, nursing homes, and other health-care facilities. They report to the administration of these facilities, coordinate with a myriad of departments (the lab, dietary, pharmacy, and so forth) and care providers (physicians, nurse practitioners, therapists, and so forth), and supervise a staff that provides care around the clock. You can see why their effective- ness has considerable influence on the quality of the care provided under their direction (Trossman, 2011).

Consider for a moment the knowledge and skills needed by a nurse manager:

■ Leadership, especially relationship building, teamwork, and mentoring skills

■ Professionalism, including advocacy for nursing staff and support of nursing roles and ethical practice

■ Advanced clinical expertise including quality improvement and evidence-based practice

■ Human resource management expertise including staff development, and performance appraisals

■ Financial management ■ Coordination of patient care, including

scheduling, work flow, work assignments, monitoring the quality of care provided, and documentation of that care ( Jones, 2010; Fennimore & Wolf, 2011)

The effective nurse manager possesses a combi na- tion of qualities: leadership, clinical expertise, and business sense. None of these alone is enough; it is the combination that prepares an individual for the complex task of managing a unit or team of health- care providers. Consider each of these briefly:

■ Leadership. All of the people skills of the leader are essential to the effective manager.

■ Clinical expertise. Without possessing clinical expertise oneself, it is very difficult to help others develop their skills and evaluate how well they have done. It is probably not necessary (or even possible) to know everything all other professionals on the team know, but it is important to be able to assess

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20 unit 1 ■ Professional Considerations

the effectiveness of their work in terms of patient outcomes.

■ Business sense. Nurse managers also need to be concerned with the “bottom line,” with the cost of providing the care that is given, especially in comparison with the benefit received from that care and the funding available to pay for it, whether from private insurance, Medicare, Medicaid, or out of the patient’s own pocket. This is a complex task that requires knowledge of budgeting, staffing, and measurement of patient outcomes.

There is some controversy over the amount of clini- cal expertise versus business sense that is needed to be an effective nurse manager. Some argue that a person can be a “generic” manager, that the job of managing people is the same no matter what tasks he or she performs. Others argue that managers must understand the tasks themselves, better than anyone else in the work group. Our position is that both clinical skill and business acumen are needed, along with excellent leadership skills.

Behaviors of an Effective Manager

Mintzberg (1989) divided a manager’s activities into three categories: interpersonal, decisional, and informational. We use these categories and have added some activities suggested by other authors (Dunham-Taylor, 1995; Montebello, 1994) and from our own observations of nurse managers (Fig. 2.2).

Interpersonal Activities The interpersonal category is one in which leaders and managers have overlapping concerns. However, the manager has some additional responsibilities that are seldom given to leaders. These include the following:

■ Networking. As we mentioned earlier, nurse managers are in pivotal positions, especially in inpatient settings where they have contact with virtually every service of the institution as well as with most people above and below them in the organizational hierarchy. This provides them with many opportunities to influence the status and treatment of staff nurses and the quality of the care provided to their patients. It is important that they “maintain the line of

sight,” or connection, between what they do as managers, patient care, and the mission of the organization (Mackoff & Triolo, 2008, p. 123). In other words, they need to keep in mind how their interactions with both their staff members and with administration affects the care provided to the patients for whom they are responsible.

■ Conflict negotiation and resolution. Managers often find themselves resolving conflicts among employees, patients, and administration. Ineffective managers often ignore people’s emotional side or mismanage feelings in the workplace (Welch & Welch, 2008).

■ Employee development. Managers are responsible for providing for the continuing learning and upgrading of the skills of their employees.

■ Coaching. It is often said that employees are the organization’s most valuable asset (Shirey, 2007). Coaching is one way in which nurse managers can share their experience and expertise with the rest of the staff. The goal is to nurture the growth and development of the

Informational

Interpersonal

Representing employees

Representing the organization

Public relations monitoring

Networking

Conflict negotiation and resolution

Employee development and coaching

Rewards and punishment

Decisional Employee evaluation Resource allocation Hiring and firing employees Planning Job analysis and redesign

Figure 2.2 Keys to effective management.

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chapter 2 ■ Manager 21 employee (the “coachee”) to do a better job through learning (McCauley & Van Velson, 2004; Shirey, 2007).

Some managers use a directive approach: “This is how it’s done. Watch me.” or “Let me show you how to do this.” Others prefer a problem-solving approach: “Let’s try to figure out what’s wrong here” (Hart & Waisman, 2005). “How do you think we can improve our outcomes?”

You can probably see the parallel with demo- cratic and autocratic leadership styles described in Chapter 1. The decision whether to be directive (e.g., in an emergency) or mutual problem-solving (e.g., when developing a long-term plan to improve infection control) will depend on the situation.

■ Rewards and punishments. Managers are in a position to provide specific rewards (e.g., salary increases, time off ) and general rewards (e.g., praise, recognition) as well as punishments (withhold pay raises, deny promotions).

Decisional Activities Nurse managers are responsible for making many decisions:

■ Employee evaluation. Managers are responsible for conducting formal performance appraisals of their staff members. Traditionally, formal reviews have been conducted once a year, but people need to know much sooner than that if they are doing well or need to improve. Effective managers are like coaches, regularly giving their staff feedback (Suddath, 2013).

■ Resource allocation. In decentralized organizations, nurse managers are often given an annual budget for their units and must allocate these resources wisely. This can be difficult when resources are very limited.

■ Hiring and firing employees. Nurse managers either make the hiring and firing decisions or participate in employment and termination decisions for their units.

■ Planning for the future. Not only is the day- to-day operation of most units complex and time-consuming, nurse managers must also look ahead to prepare themselves and their units for future changes in budgets, organizational priorities, and patient

populations. They need to look beyond the four walls of their own organization to become aware of what is happening to their competition and to the health-care system (Kelly & Nadler, 2007).

■ Job analysis and redesign. In a time of extreme cost sensitivity, nurse managers are often required to analyze and redesign the work of their units to make them as efficient as possible.

Informational Activities Nurse managers often find themselves in positions within the organizational hierarchy in which they acquire much information that is not available to their staff. They also have much information about their staff that is not readily available to the admin- istration, placing them in a strategic position within the information web of any organization. The effective manager uses this knowledge for the benefit of both the staff and the organization. The following are some examples:

■ Spokesperson. Nurse managers often speak for administration when relaying information to their staff members. Likewise, they often speak for staff members when relaying information to administration. You could think of them as central information clearinghouses, acting as gatherers and disseminators of information to people above and below them in the organizational hierarchy (Shirey, Ebright, & McDaniel, 2008, p. 126).

■ Monitoring. Nurse managers are also expert “sensors,” picking up early signs (information) of problems before they grow too big (Shirey, Ebright, & McDaniel, 2008). They are expected to monitor the many and various activities of their units or departments, including the number of patients seen, average length of stay, and important patient outcomes such as infection rates, fall rates, and so forth. They also monitor the staff (e.g., absentee rates, tardiness, unproductive time), the budget (e.g., money spent, money left in comparison with money needed to operate the unit), and the costs of procedures and services provided, especially those that are variable such as overtime or disposable vs. nondisposable medical supplies (Dowless, 2007).

■ Reporting. Nurse managers share information with their patients, staff members, and

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22 unit 1 ■ Professional Considerations

employers. This information may be related to the results of their monitoring efforts, new developments in health care, policy changes, and so forth.

Review Table 2-2, Bad Management Styles, to compare what you have just read about effective nurse managers with descriptions of some of the most common ineffective approaches to being a manager.

Conclusion

Nurse managers have complex, responsible posi- tions in health-care organizations. Ineffective man- agers may do harm to their employees, their

patients, and to the organization, while effective managers can help their staff members grow and develop as health-care professionals providing the highest quality care to their patients.

If you have wondered why there are so many conflicting and overlapping theories of leadership and management, it is because management theory is still at an immature (not fully developed) stage as well as being prone to fads (Micklethwait in Wooldridge, 2011). Even so, there is still much that is useful in the theories and much to be learned from them.

table 2-2

Bad Management Styles These are the types of managers you do not want to be and for whom you do not want to work: Know-it-all Self-appointed experts on everything, these managers do not listen to anyone else. Emotionally remote Isolated from the staff and the work going on, these managers do not know what is going on in the

workplace and cannot inspire others. Purely mean Mean, nasty, and dictatorial, these managers look for problems and reasons to criticize. They

diminish people instead of developing them. Overly nice Desperate to please everyone, these managers agree to every idea and request, causing confusion

and spending too much money on useless projects. Afraid to decide Indecisive managers may announce goals for their unit but fail to be clear about their expectations,

assign responsibility, or set deadlines for accomplishment. In the name of fairness, these managers may not distinguish between competent and incompetent, or hardworking and unproductive employees, thus creating an unfair reward system.

Source: Based on Welch, J. & Welch, S. (2007, July 23). Bosses who get it all wrong. Bloomberg Businessweek, 88; Schaffer, R.H. (2010/September). Mistakes leaders keep making. Harvard Business Review, 87–91; Wiseman, L., & McKeown, A. (2010/May). Bringing out the best in your people. Harvard Business Review, Reprint R1005K, 1–5.

Study Questions

1. Why should new graduates decline nursing management positions? At what point do you think a nurse is ready to assume managerial responsibilities?

2. Which theory, scientific management or human relations, do you believe is most useful to nurse managers? Explain your choice.

3. Compare servant leadership with scientific management. Which approach do you prefer? Why? 4. Describe your ideal nurse manager in terms of the person for whom you would most like to

work. Then describe the worst nurse manager you can imagine, and explain why this person would be very difficult to work with.

5. List 10 behaviors of nurse managers and then rank them from least to most important. What rationale(s) did you use in ranking them?

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chapter 2 ■ Manager 23

Case Studies to Promote Critical Reasoning

Case I Joe Garcia has been an operating room nurse for 5 years. He is often on call on Saturdays and Sundays, but he enjoys his work and knows that he is good at it.

Joe was called to come in on a busy Saturday afternoon just as his 5-year-old daughter’s birthday party was about to begin. “Can you find someone else just this once?” he asked the nurse manager who called him. “I should have let you know in advance that we have an important family event today, but I just forgot. If you can’t find someone else, call me back, and I’ll come right in.” Joe’s manager was furious. She said, “I don’t have time to make a dozen calls. If you knew that you wouldn’t want to come in today, you should not have accepted on-call duty. We pay you to be on call, and I expect you to be here in 30 minutes, not 1 minute later, or there will be consequences.”

Joe decided that he no longer wanted to work in that institution. With his 5 years of operating room experience, he quickly found another position in an organization that was more supportive of its staff. 1. What style of leadership and school of management seemed to be preferred by Joe Garcia’s

manager? 2. What style of leadership and school of management were preferred by Joe? 3. Which of the listed qualities of leaders and managers did the nurse manager display? Which

behaviors? Which ones did the nurse manager not display? 4. If you were Joe, what would you have done? If you were the nurse manager, what would you

have done? Why? 5. Who do you think was right, Joe or the nurse manager? Why? Case II Sung Lee completed her 2-year associate degree in nursing right after high school. Upon graduation, she was offered a staff position at Harbordale nursing home and rehabilitation center where she had volunteered during high school. Most of her classmates accepted positions in local hospitals, but Sung Lee felt comfortable at Harbordale and had loved her volunteer work there. She thought it would be an advantage to already know many of the staff at Harbordale.

The director of nursing thought it would be best to place Sung Lee on a short-term unit. Most of the patients in the unit were recently discharged from the hospital and still recovering from an acute event such as stroke, injury, or extensive surgery. Sung Lee found her assignment challenging but satisfying. She admired her nurse manager, an experienced clinical nurse leader who became her mentor.

Six months later, the director of nursing called Sung Lee into her office. “Sung Lee,” she said, “we are very pleased with your work. You have been a quick learner and very caring nurse. Your colleagues, patients, and physicians all speak well of you.”

“Thank you,” replied Sung Lee. “I know there’s still a lot for me to learn, but I really love my work here.”

“You may not be aware of this,” continued the director of nursing, “but your nurse manager will be retiring next month. Our policy at Harbordale is to promote from within whenever possible, and I’d like to offer you her position. It’s a little soon after graduation, but I’m sure you can handle it.”

Sung Lee gasped. “I’m honored that you would consider me for this position. May I have a few days to think it over?”

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24 unit 1 ■ Professional Considerations

1. Why did the director of nursing at Harbordale offer the nurse manager position to Sung Lee? If you had been in the director’s position, would you have selected Sung Lee for the nurse manager position? Why or why not?

2. If Sung Lee does accept the nurse manager position, what do you think her first month will be like? Write a scenario that describes her first month as a nurse manager.

3. If Sung Lee declines this offer, how do you think the director of nursing will respond? 4. Write a list of typical nurse manager roles and responsibilities. For each one indicate how

prepared you are to assume each role or responsibility and what you would need to prepare yourself to assume this responsibility.

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chapter 2 ■ Manager 25

References Dantley, M.E. (2005). Moral leadership: Shifting the

management paradigm. In English, F.W., The sage handbook of educational leadership (pp. 34–46). Thousand Oaks, Calif.: Sage Publications.

Dowless, R.M. (2007). Your guide to costing methods and terminology. Nursing Management, 38(4), 52–57.

Dunham-Taylor, J. (1995). Identifying the best in nurse executive leadership. Journal of Nursing Administration, 25(7/8), 24–31.

Fennimore, L., & Wolf, G. (2011). Nurse manager leadership development, Journal of Nursing Administration, 41(5), 204–210.

Greenleaf, R.K. (2004). Who is the servant-leader? In Spears, L.C., & Lawrence, M., Practicing servant- leadership. New York: Jossey-Bass.

Hart, L.B., & Waisman, C.S. (2005). The leadership training activity book. New York: AMACOM.

Hunter, J.C. (2004). The world’s most powerful leadership principle. New York: Crown Business.

Jones, R.A. (2010). Preparing tomorrow’s leaders. Journal of Nursing Administration, 40(4), 154–157.

Kelly, J., & Nadler, S. (2007, March 3–4). Leading from below. Wall Street Journal, R4.

Kovner, C.T., Brewer, C.S., Fairchild, S., et al. (2007). Newly licensed RNs’ characteristics, work attitudes, and intentions to work. American Journal of Nursing, 107(9), 58–70.

Lee, J.A. (1980). The gold and the garbage in management theories and prescriptions. Athens, Ohio: Ohio University Press.

Locke, E.A. (1982). The ideas of Frederick Taylor: An evaluation. Academy of Management Review, 7(1), 14.

Lombardi, D.N. (2001). Handbook for the new health care manager. San Francisco: Jossey-Bass/AHA Press.

Mackoff, B.L., & Triolo, P.K. (2008). Why do nurse managers stay? Building a model engagement. Part I:

Dimensions of engagement. Journal of Nursing Administration, 38(3), 118–124.

McCauley, C.D., & Van Velson, E. (eds.) (2004). The center for creative leadership handbook of leadership development. New York: Jossey-Bass.

McGregor, D. (1960). The Human Side of Enterprise. New York: McGraw-Hill.

Micklethwait, J. (2011). Foreword in Wooldridge, A. Masters of management, NY: Harper Collins.

Mintzberg, H. (1989). Mintzberg on management: Inside our strange world of organizations. New York: Free Press.

Montebello, A. (1994). Work teams that work. Minneapolis: Best Sellers Publishing.

Schaffer, R.H. (2010/September). Mistakes leaders keep making. Harvard Business Review, 87–91.

Shirey, M.R. (2007). Competencies and tips for effective leadership. Journal of Nursing Administration, 37(4), 167–170.

Shirey, M.R., Ebright, P.R., & McDaniel, A.M. (2008). Sleepless in America: Nurse managers cope with stress and complexity. Journal of Nursing Administration, 38(3), 125–131.

Spears, L.C., & Lawrence, M. (2004). Practicing servant- leadership. New York: Jossey-Bass.

Suddath, C. (2013, November 11–17). You get a D+ in teamwork. Bloomberg Businessweek, 91.

Trossman, S. (2011). Complex role in complex times. The American Nurse, 43(4), 1, 6, 7.

Welch, J., & Welch, S. (2007, July 23). Bosses who get it all wrong. Bloomberg Businessweek, 88.

Welch, J., & Welch, S. (2008, July 28). Emotional mismanagement. Bloomberg Businessweek, 84.

Wiseman, L., & McKeown, G. (2010/May). Bringing out the best in your people. Harvard Business Review, Reprint R1005k, 1–5.

Wren, D.A. (1972). The evolution of management thought. New York: Ronald Press.

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27

chapter 3 Nursing Practice and the Law

OBJECTIVES After reading this chapter, the student should be able to: ■ Identify three major sources of laws. ■ Explain the differences between various types of laws. ■ Differentiate between negligence and malpractice. ■ Explain the difference between an intentional and an

unintentional tort. ■ Explain how standards of care are used in determining

negligence and malpractice. ■ Describe how nurse practice acts guide nursing practice. ■ Explain the purpose of licensure. ■ Discuss issues of licensure. ■ Explain the difference between internal standards and

external standards. ■ Discuss advance directives and how they pertain to clients’

rights. ■ Discuss the legal implications of the Health Insurance

Portability and Accountability Act (HIPAA). OUTLINE General Principles Meaning of Law Sources of Law

The Constitution Statutes Administrative Law

Types of Laws Criminal Law Civil Law

Tort Quasi-Intentional Tort Negligence Malpractice

Other Laws Relevant to Nursing Practice Good Samaritan Laws Confidentiality

Social Networking Slander and Libel False Imprisonment Assault and Battery Standards of Practice Use of Standards in Nursing Negligence Malpractice Actions Patient’s Bill of Rights Informed Consent Staying Out of Court Prevention

Appropriate Documentation Common Actions Leading to Malpractice Suits If a Problem Arises Professional Liability Insurance End-of-Life Decisions and the Law Do Not Resuscitate Orders Advance Directives

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate)

Nursing Implications Legal Implications of Mandatory Overtime Licensure Qualifications for Licensure Licensure by Examination

NCLEX-RN Preparing for the NCLEX-RN Licensure Through Endorsement Multistate Licensure

Disciplinary Action Conclusion

The courtroom seemed cold and sterile. Scanning her surroundings with nervous eyes, Lialla decided she knew how Alice must have felt when the Queen of Hearts screamed for her head. The image of the White Rabbit running through the woods, looking at his watch, yelling, “I’m late! I’m late!” flashed before her eyes. For a few moments, she indulged herself in thoughts of being able to turn back the clock and rewrite the past. The future certainly

looked grim at that moment. The calling of her name broke her reverie. Mr. Marsh, the attorney for the plaintiff, wanted her undivided attention regarding the auspicious day when she committed a fatal medication error. That day, the client died following a cardiac arrest because Lialla failed to check the appropriate dosage and route for the medi- cation. Although she thought she should question the order, Lialla “followed the health-care provider’s

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28 unit 1 ■ Professional Considerations

order” and administered 40 mEq of potassium chlo- ride by intravenous push. Her 15 years of nursing experience meant little to the court. Because she had not followed hospital protocol and had violated an important standard of practice, Lialla stood alone. She was being sued for malpractice with the possi- bility of criminal charges should she be found guilty of contributing to the client’s death.

As client advocates, nurses have a responsibility to deliver safe care to their clients. This expectation requires that nurses have professional knowledge at their expected level of practice and be proficient in technological skills. A working knowledge of the legal system, client rights, and behaviors that may result in lawsuits helps nurses to act as client advo- cates. As long as nurses practice according to estab- lished standards of care, they may be able to avoid the kind of day in court that Lialla experienced.

General Principles

Meaning of Law The word law has several meanings. For the pur- poses of this chapter, law refers to any system of regulations that govern the conduct of individuals within a community and/or society, in response to the need for regularity, consistency, and justice (Hill & Hill, 2009). In other words, law means those rules that prescribe and control social conduct in a formal and legally binding manner. Laws are created in one of three ways:

1. Statutory laws are created by various legislative bodies, such as state legislatures or Congress. Some examples of federal statutes include the Patient Self-Determination Act of 1990 and the Americans With Disabilities Act. State statutes include the state nurse practice acts, the state boards of nursing, and the Good Samaritan Act. Laws that govern nursing practice are statutory laws.

2. Common law is the traditional unwritten law of England, based on custom and usage, which began to develop over a thousand years before the founding of the United States (Hill & Hill, 2009). It develops within the court system as judicial decisions are made in various cases and precedents for future cases are set. In this way, a decision made in one case can affect decisions made in later cases of a similar nature. Many

times a judge in a subsequent case will follow the reasoning of a judge in a previous case. Therefore, one case sets a precedent for another.

3. Administrative law includes the procedures created by administrative agencies (governmental bodies of the city, county, state, or federal government) involving rules, regulations, applications, licenses, permits, available information, hearings, appeals, and decision making (Hill & Hill, 2009). These laws are established through the authority given to government agencies, such as state boards of nursing, by a legislative body. These governing boards have the duty to meet the intent of laws or statutes.

Sources of Law The Constitution The U.S. Constitution is the foundation of Ameri- can law. The Bill of Rights, comprising the first 10 amendments to the Constitution, is the basis for protection of individual rights. These laws define and limit the power of the government and protect citizens’ freedom of speech, assembly, religion, and the press, and freedom from unwarranted intrusion by government into personal choices. State consti- tutions can expand individual rights but cannot deprive people of rights guaranteed by the U.S. Constitution.

Constitutional law evolves. As individuals or groups bring suit to challenge interpretations of the Constitution, decisions are made concerning application of the law to that particular event. An example is the protection of freedom of speech. Are obscenities protected? Can one person threaten or criticize another person? The freedom to criticize is protected; threats are not protected. The defini- tion of what constitutes obscenity is often debated and has not been fully clarified by the courts.

Statutes Statutes are written laws created by a government or accepted governing body. Localities, state legis- latures, and the U.S. Congress create statutes. Local statutes are usually referred to as ordinances. An example of a local ordinance might be a require- ment that all garbage dumpsters must be covered at all times.

At the federal level, conference committees comprising representatives of both houses of Con-

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chapter 3 ■ Nursing Practice and the Law 29 gress negotiate the resolution of any differences on wording of a bill before it is voted upon by both Houses of Congress and sent to the president to be signed into law. If the bill does not meet with the approval of the executive branch of government, the president can veto it. If that occurs, the legislative branch must have enough votes to override the veto or the bill will not become law.

Nurses have an opportunity to influence the development of statutory law both as citizens and as health-care providers. Writing to or meeting with state legislators or members of Congress is a way to demonstrate interest in such issues and their outcomes in terms of the laws passed. Passage of a new law is often a long process that includes some compromise of all interested individuals.

Administrative Law The Department of Health and Human Services, the Department of Labor, and the Department of Education are the federal agencies that administer health-care–related laws. At the state level are departments of health and mental health and licensing boards.

Administrative agencies are staffed with profes- sionals who develop the specific rules and regula- tions that direct the implementation of statutory law. These rules must be reasonable and consistent with existing statutory law and the intent of the legislature. Usually, the rules go into effect only after review and comment by affected persons or groups. For example, specific statutory laws give state nursing boards the authority to issue and revoke licenses, which means that each board of nursing has the responsibility to oversee the profes- sional nurse’s competence.

Types of Laws

Another way to look at the legal system is to divide laws into two categories: criminal law and civil law.

Criminal Law Criminal laws were developed to protect society from actions that threaten its existence. Criminal acts, although directed toward individuals, are con- sidered offenses against the state. The perpetrator of the act is punished, and the victim receives no compensation for injury or damages. There are three categories of criminal law:

1. Felony: the most serious category, including such acts as homicide, grand larceny, and nurse practice act violation

2. Misdemeanor: includes lesser offenses such as traffic violations or shoplifting of a small dollar amount

3. Juvenile: crimes carried out by individuals younger than 18 years; specific age varies by state and crime

There are occasions when a nurse breaks a law and is tried in criminal court. A nurse who obtains and/ or distributes controlled substances illegally, either for personal use or for the use of others, is violating the law. Falsification of records of controlled sub- stances is a criminal action. In some states, altering a patient record may lead to both civil and criminal action depending upon the treatment outcome. For example:

In New Jersey State v. Winter V, Nurse needed to administer a blood transfusion. Because she was in a hurry, she did not check the paperwork properly and therefore did not follow the standard of practice established for blood administration. The client was transfused with incompatible blood, suffered from a transfusion reaction, and died. Nurse V then inten- tionally attempted to conceal her conduct. She falsi- fied the records, disposed of the blood and administration equipment, and failed to notify the patient’s health-care provider of the error. The jury found Nurse V guilty of simple manslaughter and sentenced her to 5 years in prison (Sanbar, 2007).

Civil Law Civil laws usually involve the violation of one per- son’s rights by another person. Areas of civil law that particularly affect nurses are tort law, contract law, antitrust law, employment discrimination, and labor laws.

Tort The remainder of this chapter focuses primarily on tort law. By definition, tort law consists of a body of rights, obligations, and remedies that is applied by courts in civil proceedings for the purpose of providing relief for persons who have suffered harm from the wrongful acts of others. Simply put, a tort is a legal or civil wrong carried out by one person against the person or property of another. The

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30 unit 1 ■ Professional Considerations

person who sustains injury or suffers financial damage as the result of the conduct is known as the plaintiff, and the person who is responsible for causing the injury and incurs liability for the damage is known as the defendant (Loiacono, 2005). Tort law recognizes that individuals in their relationships with each other have a general duty not to harm each other. For example, as drivers of automobiles, everyone has a duty to drive safely so that others will not be harmed. A roofer has a duty to install a roof properly so that it will not collapse and injure individuals inside the structure. Nurses have a duty to deliver care in such a manner that the consumers of care are not harmed. These legal duties of care may be violated intentionally or unintentionally.

Quasi-Intentional Tort A quasi-intentional tort has its basis in speech. These are voluntary acts that directly cause injury or anguish without meaning to harm or to cause distress. The elements of cause and desire are present, but the element of intent is missing. Qua si-intentional torts usually involve problems in communication that result in damage to a person’s reputation, violation of personal privacy, or infringement of an individual’s civil rights. These include defamation of character, invasion of pri- vacy, and breach of confidentiality (Aiken, 2004, p. 139).

Negligence Negligence is the unintentional tort of acting or failing to act as an ordinary, reasonable, prudent person, resulting in harm to the person to whom the duty of care is owed (Black, 2009). The legal elements of negligence consist of duty, breach of duty, causation, and harm or injury (Gic, 2009). All four elements must be present in the determi- nation. For example, if a nurse administers the wrong medication to a client but the client is not injured, then the element of harm has not been met. However, if a nurse administers appropriate pain medication but fails to put up the side rails of the patient’s bed, and the client falls and breaks a hip, all four elements have been satisfied. The duty of care is the standard of care. The law defines stan- dard of care as that which a reasonable, prudent practitioner with similar education and experience would do or not do in similar circumstances (Gic, 2009).

Malpractice

Malpractice is the term used for professional negli- gence. When fulfillment of duties requires special- ized education, the term malpractice is used. In most malpractice suits, the facilities employing the nurses who cared for a client are named as defendants in the suit. Vicarious liability is the legal principle cited in these cases. Three doctrines, respondeat superior, the borrowed servant doctrine, and the captain of the ship doctrine fall under vicarious liability. The captain of the ship doctrine, which is an adaptation from the “borrowed servant” rules came about in a case known as McConnell v Wil- liams and refers to medical malpractice. The ruling declared that the person in charge is held account- able for all those falling under his or her supervi- sion, regardless of whether the “captain” is directly responsible for an alleged error or act of alleged negligence, and despite the others’ positions as hos- pital employees.

An important principle in understanding negli- gence is respondeat superior (“let the master answer”) (Aiken, 2004, p. 279). This doctrine holds employ- ers liable for any negligence by their employees when the employees were acting within the realm of employment and when the alleged negligent acts happened during employment (Aiken, 2004). The borrowed servant doctrine comes into play when an employee may be subject to the control and direc- tion of an entity other than the primary employer. In this situation someone other than an individual’s primary employer is responsible for his or her ac- tions. For example, an anesthesiologist supervising a resident may be held liable for the resident’s error.

Consider the following scenario:

A nursing instructor on a clinical unit in a busy metropolitan hospital instructed his students not to administer any medications unless he was present. Marcos, a second-level student, was unable to f ind his instructor, so he decided to administer digoxin to his client without supervision. The ordered dose was 0.125 mg. The unit dose came as digoxin 0.5 mg/ mL. Marcos administered the entire amount without checking the digoxin dose or the client’s blood digoxin and potassium levels. The client became toxic, developed a dysrhythmia, and was transferred to the intensive care unit. The family sued the hospital and the nursing school for malprac- tice. The nursing instructor was also sued under the

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chapter 3 ■ Nursing Practice and the Law 31 principle of respondeat superior, even though specif ic instructions had been given to the students regard- ing administering medications without direct supervision.

Other Laws Relevant to Nursing Practice

Good Samaritan Laws Fear of being sued has often prevented trained pro- fessionals from assisting during an emergency. To encourage physicians and nurses to respond to emergencies, many states developed what are now known as the Good Samaritan laws. When admin- istering emergency care, nurses and physicians are protected from civil liability by Good Samaritan laws as long as they behave in the same manner as an ordinary, reasonable, and prudent professional in the same or similar circumstances (Glannon, 2005). In other words, when assisting during an emer- gency, nurses must still observe professional stan- dards of care. However, if a payment is received for the care given, the Good Samaritan laws do not hold.

Confidentiality It is possible for nurses to be involved in lawsuits other than those involving negligence. For example, clients have the right to confidentiality, and it is the duty of the professional nurse to ensure this right. This assures the client that information obtained by a nurse while providing care will not be com- municated to anyone who does not have a need to know. This includes giving information by tele- phone to individuals claiming to be related to a client, giving information without a client’s signed release, or removing documents from a health-care provider with a client’s name or other information.

The Health Insurance Portability and Account- ability Act (HIPAA) of 1996 was passed as an effort to preserve confidentiality, protect the privacy of health information, and improve the portability and continuation of health-care coverage. The HIPAA gave Congress until August 1999 to pass this legislation. Congress failed to act, and the Department of Health and Human Services took over developing the appropriate regulations (Char- ters, 2003). The latest version of this privacy act was published in the Federal Register in 2002 (Charters, 2003).

The increased use of electronic sources of do- cumentation and transfer of client information presents many confidentiality issues. It is impor- tant for nurses to be aware of the guidelines pro- tecting the sharing and transfer of information through electronic sources. Most health-care insti- tutions have internal procedures to protect client confidentiality.

Consider the following example:

Bill was admitted to the hospital for pneumonia. With Bill ’s permission, an HIV test was per- formed, and the result was positive. This infor- mation was available on the computerized laboratory result printout. A nurse inadvertently left the laboratory results on the computer screen, which was partially facing the hallway. One of Bill ’s coworkers, who had come to visit him, saw the report on the screen. This individual reported the test results to Bill ’s supervisor. When Bill returned to work, he was f ired for “poor job perfor- mance,” although he had had superior job evalua- tions. In the process of f iling a discrimination suit against his employer, Bill discovered that the infor- mation on his health status had come from this source. A lawsuit was f iled against the hospital and the nurse involved based on a breach of confidentiality.

Social Networking Another issue affecting confidentiality involves social networking. The increased use of smart- phones has led to increased violations of confiden- tiality. These infractions often occur without intent yet pose a risk to clients and health-care person- nel. Posting pictures and information on social net- working sites that involve clinical experiences and/ or work experiences can present a risk to patient confidentiality and violate HIPAA regulations. Many institutions have implemented policies that affect employees and student affiliations. These policies may result in employee termination and/ or cancelling agreements with outside agencies using the health-care institution. Take the following example:

Several nursing students who received scholarships from an aff iliating health-care institution were working their required shift in the emergency department. The staff brought in a birthday cake for one of the emergency department physicians. One of

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32 unit 1 ■ Professional Considerations

the students snapped a picture of the staff with the physician and posted it on her social network page. The computer screen with the names and information of the clients in the emergency depart- ment at the time was clearly visible behind the phy- sician and the staff. Another staff member discovered this and notif ied the chief nursing off icer of the hospital. The nursing student lost her scholarship, was terminated from her job, and was required to return all monies back to the institution. Disciplin- ary actions were taken against the staff involved in the incident.

Slander and Libel Slander and libel are categorized as quasi-inten- tional torts. The term slander refers to the spoken word, and libel refers to the written word. Nurses rarely think of themselves as being guilty of slander or libel, but making a false verbal statement about a client’s condition that may result in an injury to that client is considered slander. Making a false written statement is libel. For example, verbally stating that a client who had blood drawn for drug testing has a substance abuse problem, when in fact the client does not carry that diagnosis, could be considered a slanderous statement.

Slander and libel also refer to statements made about coworkers or other individuals whom you may encounter in both your professional and edu- cational life. Think before you speak and write. Sometimes what may appear to be harmless to you, such as a complaint, may contain statements that damage another person’s credibility personally and professionally. Consider this example:

Several nurses on a unit were having diff iculty with the nurse manager. Rather than approach the manager or follow the chain of command, they decided to send a written statement to the chief executive off icer (CEO) of the hospital. In this letter, they embellished some of the incidents that occurred and took out of context statements that the nurse manager had made, changing the mean- ings of the remarks. The nurse manager was called to the CEO’s off ice and reprimanded for these events and statements, which in fact had not occurred. The nurse manager sued the nurses for slander and libel based on the premise that her personal and professional reputation had been tainted.

False Imprisonment

False imprisonment is confining an individual against his or her will by either physical (restrain- ing) or verbal (detaining) means. The following are examples:

■ Using restraints on individuals without the appropriate written consent

■ Restraining mentally challenged individuals who do not represent a threat to themselves or others

■ Detaining unwilling clients in an institution when they desire to leave

■ Keeping persons who are medically cleared for discharge for an unreasonable amount of time

■ Removing clients’ clothing to prevent them from leaving the institution

■ Threatening clients with some form of physical, emotional, or legal action if they insist on leaving

Sometimes clients are a danger to themselves and to others. Nurses need to decide on the appropri- ateness of restraints as a protective measure. Nurses should try to obtain the cooperation of the client before applying any type of restraint. The first step is to attempt to identify a reason for the risky or threatening behavior and resolve the problem. If this fails, document the need for restraints, consult with the physician, and carefully follow the institu- tion’s policies and standards of practice. Systematic documentation and continual assessment are of highest importance when caring for clients who have restraints. Any changes in client status must be reported and documented. Failure to follow these guidelines may result in greater harm to the client and possibly a lawsuit for the staff. Consider the following:

Mr. Harrison, who is 87 years old, was admitted to the hospital through the emergency department with severe lower abdominal pain of 3 days’ duration. Physical assessment revealed severe dehydration and acute distress. A surgeon was called, and an abdomi- nal laparotomy was performed, revealing a rup- tured appendix. Surgery was successful, and the client was sent to the intensive care unit for 24 hours. On transfer to the surgical floor the next day, Mr. Harrison was in stable condition. Later that night, he became confused, irritable, and anxious.

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chapter 3 ■ Nursing Practice and the Law 33 He attempted to climb out of bed and pulled out his indwelling urinary catheter. The nurse restrained him. The next day, his irritability and confusion continued. Mr. Harrison’s nurse placed him in a chair, tying him in and restraining his hands. Three hours later he was found in cardiopulmonary arrest. A lawsuit of wrongful death and false imprison- ment was brought against the nurse manager, the nurses caring for Mr. Harrison, and the institution. During discovery, it was determined that the primary cause of Mr. Harrison’s behavior was hypoxemia. A violation of law occurred with the failure of the nursing staff to notify the physician of the client’s condition and to follow the institution’s standard of practice on the use of restraints.

To protect themselves against charges of negligence or false imprisonment in such cases, nurses should discuss safety needs with clients, their families, or other members of the health-care team. Careful assessment and documentation of client status are imperative and also components of good nursing practice. Confusion, irritability, and anxiety often have metabolic causes that need correction, not restraint.

There are statutes and case laws specific to the admission of clients to psychiatric institutions. Most states have guidelines for emergency involun- tary hospitalization for a specific period of time. Involuntary admission is considered necessary when clients demonstrate a danger to themselves or others. Specific procedures and legal guidelines must be followed. A determination by a judge or administrative agency and/or certification by a specified number of health-care providers that a person’s mental health justifies his or her detention and treatment may be required. Once admitted, these clients may not be restrained unless the guide- lines established by state law and the institution’s policies provide for this possibility. Clients who voluntarily admit themselves to psychiatric institu- tions are also protected against false imprisonment. Nurses working in areas such as emergency depart- ments, mental health facilities, and so forth need to be cognizant of these issues and find out the policies of their state and employing institution.

Assault and Battery Assault is threatening to do harm. Battery is touch- ing another person without his or her consent. The significance of an assault lies in the threat:

“If you don’t stop pushing that call bell, I’ll give you this injection with the biggest needle I can find” is considered an assaultive statement. Bat- tery would occur if the injection were given when it was refused, even if medical personnel deemed it was for the “client’s good.” With few exceptions, clients have a right to refuse treatment. Holding down a violent client against his or her will and injecting a sedative is battery. Most medical treat- ments, particularly surgery, would be considered battery if clients failed to provide informed consent.

Standards of Practice

Avedis Donabedian (1988) said, “Standards are professionally developed expressions of the range of acceptable variations from a norm or criterion.” Concern for the quality of care is a major part of nursing’s responsibility to the public. Therefore, the nursing profession is accountable to the consumer for the quality of its services.

One of the defining characteristics of a profes- sion is the ability to set its own standards. Nursing standards were established as guidelines for the profession to ensure acceptable quality of care (Beckman, 1995). Standards of practice are also used as criteria to determine whether appropriate care has been delivered. In practice, they repre- sent the minimum acceptable level of care. Nurses are judged on generally accepted standards of prac- tice for their level of education, experience, posi- tion, and specialty area. Standards take many forms. Some are written and appear as criteria of pro- fessional organizations, job descriptions, agency policies and procedures, and textbooks. Others, which may be intrinsic to the custom of practice, are not found in writing (Beckman, 1995).

State boards of nursing and professional organi- zations vary by role and responsibility in relation to standards of development and implementation (ANA, 1998; 2011). Statutes written by the gov- ernment, professional organizations, and health- care institutions establish standards of practice. The nurse practice acts of individual states define the boundaries of nursing practice within the state. In Canada, the provincial and territorial associations define practice.

The courts have upheld the authority of boards of nursing to regulate standards. The boards ac- complish this through direct or delegated statutory language (ANA, 1998; 2004; 2011). The American

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Nurses Association (ANA) also has specific stan- dards of practice in general and in several clinical areas (ANA, 2010) (see Appendix 2). In Canada, the colleges of registered nurses and the registered nurses associations of the various provinces and territories have published practice standards. These may be found at www.cna-aiic.ca.

Institutions develop internal standards of prac- tice. The standards are usually explained in a spe- cific institutional policy (for example, guidelines for the appropriate administration of a specific chemo- therapeutic agent), and the institution includes these standards in its policy and procedure manuals. The guidelines are based on current literature and research. It is the nurse’s responsibility to meet the institution’s standards of practice. It is the institu- tion’s responsibility to notify the health-care per- sonnel of any changes and instruct the personnel about the changes. Institutions may accomplish this task through written memos or meetings and in- service education.

With the expansion of advanced nursing prac- tice, it has become particularly important to clarify the legal distinction between nursing and medi- cal practice. It is important to be aware of the boundaries between these professional domains be- cause crossing them can result in legal conse- quences and disciplinary action. The nurse practice act and related regulations developed by most state legislatures and state boards of nursing help to clarify nursing roles at the various levels of practice.

Use of Standards in Nursing Negligence Malpractice Actions When omission of prudent care or acts committed by a nurse or those under his or her supervision cause harm to a client, standards of nursing prac- tice are among the elements used to determine whether malpractice or negligence exists. Other criteria may include but are not limited to (ANA, 1998; 2011):

■ State, local, or national standards ■ Institutional policies that alter or adhere to the

nursing standards of care ■ Expert opinions on the appropriate standard of

care at the time ■ Available literature and research that

substantiates a standard of care or changes in the standard

Patient’s Bill of Rights

In 1973 the American Hospital Association approved a statement called the Patient’s Bill of Rights. It was revised in October 1992. Patient rights were developed with the belief that hospitals and health-care institutions would support these rights with the goal of delivering effective client care. In 2003 the Patient’s Bill of Rights was replaced by the Patient Care Partnership. These standards were derived from the ethical principle of autonomy. This document may be found at www .aha.org/advocacy-issues/communicatingpts/pt -care-partnership.shtml.

Informed Consent Informed consent is a legal document in all 50 states. It requires physicians to divulge the benefits, risks, and alternatives to a suggested treatment, nontreatment, or procedure. It allows for fully informed, rational persons to be involved in choices about their health care (Marr, 2003).

Without consent, many of the procedures per- formed on clients in a health-care setting may be considered battery or unwarranted touching. When clients consent to treatment, they give health-care personnel the right to deliver care and perform specific treatments without fear of prosecution. Although physicians are responsible for obtaining informed consent, nurses often find themselves involved in the process.

It is the physician’s responsibility to give infor- mation to a client about a specific treatment or medical intervention (Giese v. Stice, 1997). While the nurse may witness the signature of a patient for a procedure, or surgery, the nurse should not be providing the details such as the benefits, risk, or possible outcomes. The individual institution is not responsible for obtaining the informed consent unless (1) the physician or practitioner is employed by the institution or (2) the institution was aware or should have been aware of the lack of informed consent and did not act on this fact (Guido, 2001). Some institutions require the physician or indepen- dent practitioner to obtain his or her own informed consent by obtaining the client’s signature at the time the explanation for treatment is given.

Although some nurses may believe that they only need to obtain the client’s signature on the informed consent document, nursing professionals have a larger responsibility in evaluating a client’s

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chapter 3 ■ Nursing Practice and the Law 35 ability to give informed consent. The nurse’s role is to: (a) act as the patient’s advocate, (b) protect the patient’s dignity, (c) identify any fears, and (d) determine the patient’s level of understanding and approval of the proposed care.

Every client brings a different and unique response depending on his or her personality, level of education, emotions, and cognitive status. A good practice is to ask a client to restate the infor- mation offered. This helps confirm that the client has received an appropriate amount of information and has understood it. The nurse is obliged to report any concerns about the client’s understand- ing regarding what he or she has been told, or any concerns about the client’s ability to make decisions.

The informed consent form should contain all the possible negative outcomes as well as the posi- tive ones. The following are some criteria to help ensure that a client has given an informed consent (Berman & Snyder, 2012):

■ A mentally competent adult has voluntarily given the consent.

■ The client understands exactly to what he or she is consenting.

■ The consent includes the risks involved in the procedure, alternative treatments that may be available, and the possible result if the treatment is refused.

■ The consent is written. ■ A minor’s parent or guardian usually gives

consent for treatment.

Ideally, a nurse should be present when the health- care provider who is performing the treatment, surgery, or procedure is explaining the benefits and risks to the client.

To be able to give informed consent, the client must be fully informed. Clients have the right to refuse treatment, and nurses must respect this right. If a client refuses the recommended treatment, he or she must be informed of the possible conse- quences of this decision.

Implied consent occurs when consent is assumed. This may be an issue in an emergency when an individual is unable to give consent, as in the fol- lowing scenario:

An elderly woman is involved in a car accident on a major highway. The paramedics called to the scene

f ind her unresponsive and in acute respiratory dis- tress; her vital signs are unstable. The paramedics immediately intubate her and begin treating her cardiac dysrhythmias. Because she is unconscious and unable to give verbal consent, there is an implied consent for treatment.

Staying Out of Court

Prevention Unfortunately, the public’s trust in the medical pro- fession has declined over recent years. Consumers are better informed and more assertive in their approach to health care. They demand good and responsible care. If clients and their families per- ceive that behaviors are uncaring or that attitudes are impersonal, they are more likely to sue for what they view as errors in treatment.

The same applies to nurses. If nurses demon- strate an interest in clients and their families and display caring behaviors toward clients, a relation- ship develops. Individuals usually do not initiate lawsuits against those they view as “caring friends.” The potential to change the attitudes of health-care consumers is within the power of health-care per- sonnel. Demonstrating care and concern and making clients and families aware of choices and methods help decrease liability. Nurses who involve clients and their families in decisions about care reduce the likelihood of a lawsuit. Tips to prevent legal problems are listed in Box 3-1.

All health-care personnel are accountable for their own actions and adherence to the accepted

• Keep yourself informed regarding new research related to your area of practice.

• Insist that the health-care institution keep personnel apprised of all changes in policies and procedures and in the management of new technological equipment.

• Always follow the standards of care or practice for the institution.

• Delegate tasks and procedures only to appropriate personnel.

• Identify clients at risk for problems, such as falls or the development of decubiti.

• Establish and maintain a safe environment. • Document precisely and carefully. • Write detailed incident reports, and file them with the

appropriate personnel or department. • Recognize certain client behaviors that may indicate the

possibility of a lawsuit.

box 3-1

Tips for Avoiding Legal Problems

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standards of health care. Most negligence and mal- practice cases arise from a violation of the accepted standards of practice and the policies of the employ- ing institution. Common causes of negligence are listed in Table 3-1. Expert witnesses are called to cite the accepted standards and assist attorneys in formulating the legal strategies pertaining to those standards. For example, most medication errors can be traced to a violation of the accepted standard of medication administration, originally referred to as the Five Rights (Kozier et al., 1995; Taylor, Lillis, & LeMone, 2008). These were later amended to Seven Rights (Balas, Scott, & Rogers, 2004). In 2011, one more criterion was added, now making Eight Rights (Eisenhauer et al., 2007).

More recently Elliot and Liu (2010) proposed Nine Rights.

1. Right drug 2. Right dose 3. Right route 4. Right time 5. Right client 6. Right reason 7. Right documentation 8. Right form 9. Right response

Marcos, the nursing student described earlier in this chapter, violated the right-dose principle and therefore made a medication error.

Appropriate Documentation

The adage “not documented, not done” holds true in nursing. According to the law, if something has not been documented, then the responsible party did not do whatever needed to be done. If a nurse did not “do” something, he or she will be left open to negligence or malpractice charges.

Nursing documentation needs to be legally credible. Legally credible documentation is an accurate accounting of the care the client received. It also indicates the competence of the individual who delivered the care.

Charting by exception creates defense difficul- ties. When this method of documentation is used, investigators need to review the entire patient record in an attempt to reconstruct the care given to the client. Clear, concise, and accurate docu- mentation helps nurses when they are named in lawsuits. Often, this documentation clears the indi- vidual of any negligence or malpractice. Documen- tation is credible when it is:

■ Contemporaneous (documenting at the time care was provided)

■ Accurate (documenting exactly what was done) ■ Truthful (documenting only what was done) ■ Appropriate (documenting only what could be

discussed comfortably in a public setting)

Box 3-2 lists some documentation tips.

table 3-1

Common Causes of Negligence Problem Prevention

Client falls Identify clients at risk. Place notices about fall precautions. Follow institutional policies on the use of restraints. Always be sure beds are in their lowest positions. Use side rails appropriately.

Equipment injuries Check thermostats and temperature in equipment used for heat or cold application. Check wiring on all electrical equipment.

Failure to monitor Observe IV infusion sites as directed by institutional policy. Obtain and record vital signs, urinary output, cardiac status, etc., as directed by institutional policy

and more often if client condition dictates. Check pertinent laboratory values.

Failure to communicate Report pertinent changes in client status. Document changes accurately. Document communication with appropriate source.

Medication errors Follow the Seven Rights. Monitor client responses. Check client medications for multiple drugs for the same actions.

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chapter 3 ■ Nursing Practice and the Law 37

It is not good practice to sign off on medications for all patients for a shift before the medications are administered. Doing so is considered a fraudu- lent act and may leave a nurse open to charges of negligence in the form of a medication error if the medications are then not administered as docu- mented. If injury occurs because the patient never received a medication, and the nurse documented that the patient received it, the nurse can be charged with criminal negligence.

Nursing units are busy and often understaffed. These realities exist but should not be allowed to interfere with the safe delivery of health care. Clients have a right to safe and effective health care, and nurses have an obligation to deliver this care.

Common Actions Leading to Malpractice Suits ■ Failure to assess a client appropriately ■ Failure to report changes in client status to the

appropriate personnel ■ Failure to document in the patient record ■ Altering or falsifying a patient record ■ Failure to obtain informed consent ■ Failure to report a coworker’s negligence or

poor practice ■ Failure to provide appropriate education to a

client and/or family members ■ Violation of internal or external standards of

practice

In the case Tovar v. Methodist Healthcare (2005), a 75-year-old female client came to the emergency department complaining of a headache and weak- ness in the right arm. Although an order for admis- sion to the neurological care unit was written, the client was not transported until 3 hours later. After the client was in the unit, the nurses called one physician regarding the client’s status. Another physician returned the call 90 minutes later. Three hours later, the nurses called to report a change in the client’s neurological status. A STAT computed tomography scan was ordered, which revealed a massive brain hemorrhage. The nurses were cited for the following:

1. Delay in transferring the client to the neurological unit

2. Failure to advocate for the client

The client presented with an acute neurological problem requiring admission to an intensive care unit where appropriate observation and interven- tions were available. A delay in transfer may lead to delay in appropriate treatment. According to the American Association of Neuroscience Nursing standards of practice (2012), nurses need to accu- rately assess the client’s changing neurological status and advocate for the client. In this instance, the court stated that the nurses should have been

Medications • Always chart the time, route, dose, and response. • Always chart PRN medications and the client response. • Always chart when a medication was not given, the reason (e.g., client in Radiology, Physical Therapy; do not chart that

the medication was not on the floor), and the nursing intervention. • Chart all medication refusals, and report them. Physician Communication • Document each time a call is made to a physician, even if he or she is not reached. Include the exact time of the call. If

the physician is reached, document the details of the message and the physician’s response. • Read verbal orders back to the physician, and confirm the client’s identity as written on the chart. Chart only verbal

orders that you have heard from the source, not those told to you by another nurse or unit personnel. Formal Issues in Charting • Before writing on the chart, check to be sure you have the correct patient record. • Check to make sure each page has the client’s name and the current date stamped in the appropriate area. • If you forgot to make an entry, chart “late entry,” and place the date and time at the entry. • Correct all charting mistakes according to the policy and procedures of your institution. • Chart in an organized fashion, following the nursing process. • Write legibly and concisely, and avoid subjective statements. • Write specific and accurate descriptions. • When charting a symptom or situation, chart the interventions taken and the client response. • Document your own observations, not those that were told to you by another party. • Chart frequently to demonstrate ongoing care, and chart routine activities. • Chart client and family teaching and their response.

box 3-2

Some Documentation Guidelines

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38 unit 1 ■ Professional Considerations

more assertive in attempting to reach the physician and request a prompt medical evaluation. The court sided with the family, agreeing with the plaintiff ’s medical expert’s conclusion that the client’s death was related to improper management by the nursing staff.

If a Problem Arises When served with a summons or complaint, people often panic, allowing fear to overcome reason.

First, simply answer the complaint. Failure to do this may result in a default judgment, causing greater distress and difficulties.

Second, many things can be done to protect oneself if named in a lawsuit. Legal representation can be obtained to protect personal property. Never sign any documents without consulting the mal- practice insurance carrier or a legal representative. If you are personally covered by malpractice insur- ance, notify the company immediately and follow its instructions carefully.

Institutions usually have lawyers to defend themselves and their employees. Whether or not you are personally insured, contact the legal depart- ment of the institution where the act took place. Maintain a file of all papers, proceedings, meetings, and telephone conversations about the case. Do not withhold any information from your attorneys, even if that information can be harmful to you. A pending or ongoing legal case should not be dis- cussed with coworkers or friends.

Let the attorneys and the insurance company help decide how to handle the difficult situation. They are in charge of damage control. Concealing information usually causes more damage than dis- closing it.

Sometimes, nurses believe they are not being adequately protected or represented by the attor- neys from their employing institution. If this happens, consider hiring a personal attorney who is experienced in malpractice law. This information can be obtained through either the state bar asso- ciation or the local trial lawyers association.

Anyone has the right to sue; however, that does not mean that there is a case. Many negligence and malpractice cases find in favor of the health-care providers, not the client or the client’s family. The following case demonstrates this situation:

The Supreme Court of Arkansas heard a case that originated from the Court of Appeals in Arkansas. A client died in a single-car motor vehicle accident

shortly after undergoing an outpatient colonoscopy performed under conscious sedation. The family sued the center for performing the procedure and permit- ting the client to drive home. The court agreed that sedation should not be administered without the confirmation of a designated driver for later. It also agreed that an outpatient facility needs to have directives stating that nurses and physicians may not administer sedation unless transportation is available for later. However, the court ruled physi- cians and nurses may rely on information from the client. If the client states that someone will be avail- able for transportation after the procedure, sedation may be administered. The second aspect of the case revolved around the client’s insistence on leaving the facility and driving himself. When a client leaves against medical advice, the health-care personnel have a legal duty to warn and strongly advise the client against the highly dangerous action. However, nurses and physicians do not have a legal right to restrain the client physically, keep his clothes, or take away car keys. Nurses are not obligated to call a taxi, call the police, admit the client to the hospital, or personally escort the client home if the client insists on leaving. Clients have some responsibility for their own safety (Young v GastroIntestinal Center, Inc., 2005). In this case, the nurses acted appropriately. They adhered to the standard of prac- tice, documented that the client stated that someone would be available to transport him home, and ful- filled the duty to warn.

Professional Liability Insurance

We live in a litigious society. Although there are a variety of opinions on the issue, in today’s world nurses need to consider obtaining professional lia- bility insurance (Aiken, 2004). Various forms of professional liability insurance are available. These policies have been developed to protect nurses against personal financial losses if they are involved in a medical malpractice suit. If a nurse is charged with malpractice and found guilty, the employing institution has the right to sue the nurse to reclaim damages. Professional malpractice insurance pro- tects the nurse in these situations.

End-of-Life Decisions and the Law

When a heart ceases to beat, a client is in a state of cardiac arrest. In health-care institutions and in the community, it is common to begin cardiopul-

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chapter 3 ■ Nursing Practice and the Law 39 monary resuscitation (CPR) when cardiac arrest occurs. In health-care institutions, an elaborate mechanism is put into action when a client “codes.” Much controversy exists concerning when these mechanisms should be used and whether individu- als who have no chance of regaining full viability should be resuscitated.

Do Not Resuscitate Orders A do not resuscitate (DNR) order is a specific directive to health-care personnel not to initiate CPR measures. Only a physician can write a DNR order, usually after consulting with the client or family. Other members of the health-care team are expected to comply with the order. Clients have the right to request a DNR order. However, they may make this request without a full understanding of what it really means. Consider the following example:

When Mrs. Vincent, 58 years old, was admitted to the hospital for a hysterectomy, she stated, “I want to be made a DNR.” The nurse, concerned by the statement, questioned Mrs. Vincent’s understanding of a DNR order. The nurse asked her, “Do you mean that if you are walking down the hall after your surgery and your heart stops beating, you do not want the nurses or physicians to do anything? You want us to just let you die?” Mrs. Vincent responded with a resounding, “No, that is not what I mean. I mean if something happens to me and I won’t be able to be the way I am now, I want to be a DNR!” The nurse then explained the concept of a DNR order.

New York state has one of the most complete laws regarding DNR orders for acute and long-term care facilities. The New York law sets up a hierarchy of surrogates who may ask for a DNR status for incompetent clients. The state has also ordered that all health-care facilities ask clients their wishes regarding resuscitation (www.ny.gov). The ANA advocated that every facility have a written policy regarding the initiation of such orders (ANA, 1992). The client, or if the client is unable to speak for himself or herself, a family member or guardian should make clear the client’s preference for either having as much as possible done or withholding treatment (see the next section, Advance Direc- tives). After the Terri Schiavo case the ANA recon- firmed its stance on this issue (ANA, 2005).

Elements to include in a DNR order are listed in Box 3-3.

Advance Directives The legal dilemmas that may arise in relation to DNR orders often require court decisions. For this reason, in 1990, Senator John Danforth of Missouri and Senator Daniel Moynihan of New York intro- duced the Patient Self-Determination Act to address questions regarding life-sustaining treat- ment. The act was created to allow people the opportunity to make decisions about treatment in advance of a time when they might become unable to participate in the decision-making process. Through this mechanism, families can be spared the burden of having to decide what the family member would have wanted.

Federal law requires that health-care institutions that receive federal money (from Medicare, for example) inform clients of their right to create advance directives. The Patient Self-Determination Act (S.R. 13566) provides guidelines for develop- ing advance directives concerning what will be done for individuals if they are no longer able to participate actively in making decisions about care options. The act states that institutions must:

■ Provide information to every client. On admission, all clients must be informed in writing of their rights under state law to accept or refuse medical treatment while they are competent to make decisions about their care. This includes the right to execute advance directives.

■ Document. All clients must be asked whether they have a living will or have chosen a durable power of attorney for health care (also

• Statement of the institution’s policy that resuscitation will be initiated unless there is a specific order to withhold resuscitative measures

• Statement from the client regarding specific desires • Description of the client’s medical condition to justify a

DNR order • Statement about the role of family members or

significant others • Definition of the scope of the DNR order • Delineation of the roles of various caregivers

American Nurses Association. (1992). Position statement on nursing care and do not resuscitate decisions. Washington, DC: ANA.

box 3-3

Elements to Include in a DNR Order

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40 unit 1 ■ Professional Considerations

known as a health-care surrogate). The response must be indicated on the medical record, and a copy of the documents, if available, should be placed on the client’s chart.

■ Educate. Nurses, other health-care personnel, and the community need to understand what the Patient Self-Determination Act and state laws regarding advance directives require.

■ Be respectful of clients’ rights. All clients are to be treated with respectful care regardless of their decision regarding life-prolonging treatments.

■ Have cultural humility. Recognize that culture affects clients’ decisions regarding end- of-life care. Nurses should familiarize themselves with the cultural and spiritual beliefs of their clients in order to deliver culturally sensitive care.

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate) The two most common forms of advance directives are living wills and durable power of attorney for health care (health-care surrogate). Living wills and other advance directives describe individual prefer- ences regarding treatment in the event of a serious accident or illness. These legal documents indicate an individual’s wishes regarding care decisions (www.mayoc linic.com/health/l iving-wil ls/ HA00014).

A living will is a legally executed document that states an individual’s wishes regarding the use of life-prolonging medical treatment in the event that he or she is no longer competent to make informed treatment decisions on his or her own behalf and is suffering from a terminal condition (Catalano, 2000; Flarey, 1991). A condition is considered ter- minal when, to a reasonable degree of medical cer- tainty, there is little likelihood of recovery or the condition is expected to cause death. A terminal condition may also refer to a persistent vegetative state characterized by a permanent and irreversible condition of unconsciousness in which there is (1) absence of voluntary action or cognitive behavior of any kind and (2) an inability to communicate or interact purposefully with the environment (Hickey, 2008).

Another function of an advance directive is to designate a health-care surrogate. The role of the health-care surrogate is to make the client’s wishes

known to medical and nursing personnel. Chosen by the client, the health-care surrogate is usually a family member or close friend. Imperative in the designation of a health-care surrogate is a clear understanding of the client’s wishes should the need arise to know them.

In some situations, clients are unable to express themselves adequately or competently, although they are not terminally ill. For example, clients with advanced Alzheimer’s disease or other forms of dementia cannot communicate their wishes; clients under anesthesia are temporarily unable to com- municate; and the condition of comatose clients does not allow for expression of health-care wishes. In these situations, the health-care surrogate can make treatment decisions on behalf of the client. However, when a client regains the ability to make his or her own decisions and is capable of ex- pressing them effectively, he or she resumes con- trol of all decision making pertaining to medical treatment (Reigle, 1992). Nurses and physicians may be held accountable when they go against a client’s wishes regarding DNR orders and advance directives.

In the case of Wendland v. Sparks (1998), the physician and nurses were sued for “not initiating CPR.” In this case, the client had been in the hos- pital for more than 2 months for lung disease and multiple myeloma. Although improving at the time, during the hospitalization the client had experienced three cardiac arrests. Even after this, she had not requested a DNR order. Her family had not discussed this either. After one of the arrests, the client’s husband had told the physician that he wanted his wife placed on artificial life support if it was necessary (Guido, 2001). The client had a fourth cardiac arrest. One nurse went to obtain the crash cart, and another went to get the physician who happened to be in the area. The physician checked the client’s heart rate, pupils, and respirations and stated, “I just cannot do it to her.” (Guido, 2001, p. 158). She ordered the nurses to stop the resuscitation, and the physician pro- nounced the death of the client. The nurses stated that if they had not been given a direct order they would have continued their attempts at resuscita- tion. “The court ruled that the physician’s judgment was faulty and that the family had the right to sue the physician for wrongful death” (Guido, 2001, p. 158). The nurses were cleared in this case because they were following a physician’s order.

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chapter 3 ■ Nursing Practice and the Law 41 Nursing Implications

The Patient Self-Determination Act does not specify who should discuss treatment decisions or advance directives with clients. Because directives are often implemented on nursing units, however, nurses must be knowledgeable about living wills and health-care surrogates and be prepared to answer questions that clients may have about direc- tives and the forms used by the health-care institution.

The responsibility for creating an awareness of individual rights often falls on nurses because they are client advocates. It is the responsibility of the health-care institution to educate personnel about its policies so that nurses and others involved in client care can inform health-care consumers of their choices. Nurses who are unsure of the policies in their health-care institution should contact the appropriate department.

Legal Implications of Mandatory Overtime

Although mostly a workplace and safety issue, there are legal implications to mandatory overtime. Due to nursing shortages, hospitals have increasingly forced nurses to work overtime (ANA, 2011). The ANA conducted a survey of almost 220,000 RNs from 13,000 nursing units in over 550 hospitals. The survey produced a 70% report rate and the results indicated that:

■ 54% of nurses in adult medical units and emergency rooms revealed that they do not have sufficient time with patients;

■ The amount of overtime has increased during the past year with 43% of all RNs working extra hours because the unit is short staffed or busy; and

■ Inadequate staffing affected unit admissions, transfers, and discharges more than 20% of the time (ANA, 2011).

Overtime causes physical and mental fatigue, increased stress, and decreased concentration. Sub- sequently, these conditions lead to medical errors such as failure to assess appropriately, report, docu- ment, and administer medications safely. This prac- tice of overtime ignores other responsibilities nurses

have outside of their professional lives, which affects their mood, motivation, and productivity (Bae, Brewer, & Kovner, 2011).

Forced overtime causes already fatigued nurses to deliver nursing care that may be less than optimum, which in turn may lead to negligence and malpractice. This can result in the nurse losing his or her license and perhaps even facing a wrongful death suit due to an error in judgment. Needleman, Buerhaus, Pankratz, Liebson, Stevens, and Harris (2011) found that patient mortality increased by 2% on nursing units that had nurses working shifts 8 hours or more over their scheduled time due to registered nurse short staffing issues. Many states have implemented legislation restricting manda- tory overtime for nurses. It is important for nurses to know and understand the laws of their particular state dealing with this issue.

Nurses practice under state or provincial (Canada) nurse practice acts, which state that nurses are held accountable for the safety and welfare of their clients. Once a nurse accepts an assignment for the client, that nurse becomes liable under his or her license.

Licensure

Licensure is defined by the National Council of State Boards of Nursing as “the process by which boards of nursing grant permission to an indi- vidual to engage in nursing practice after determin- ing that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activi- ties are complex, require specialized knowledge and skill and independent decision making.” (NCSBN, 2012). Licenses are given by a govern- ment agency to allow an individual to engage in a professional practice and use a specific title. State boards of nursing issue nursing licenses, thus limit- ing practice to a specific jurisdiction (Blais & Hayes, 2011).

Licensure can be mandatory or permissive. Permissive licensure is a voluntary arrangement whereby an individual chooses to become licensed to demonstrate competence. However, the license is not required to practice. Mandatory licensure requires a nurse to be licensed in order to practice. In the United States and Canada, licensure is mandatory.

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42 unit 1 ■ Professional Considerations

Qualifications for Licensure

The basic qualification for licensure requires gradu- ation from an approved nursing program. In the United States, states may add additional require- ments, such as disclosures regarding health or med- ications that could affect practice. Most states require disclosure of criminal conviction.

Licensure by Examination A major accomplishment in the history of nursing licensure was the creation of the Bureau of State Boards of Nurse Examiners. The formation of this agency led to the development of an identical examination in all states. The original examination, called the State Board Test Pool Examination, was created by the testing department of the National League for Nursing. This was done through a collaborating contract with the state boards. Initially, each state determined its own passing score; however, the states did adopt a common passing score. The examination is called the NCLEX-RN and is used in all states and ter- ritories of the United States. This test is prepared and administered through a testing company, Pearson Professional Testing of Minnesota (Ellis & Hartley, 2004).

NCLEX-RN The NCLEX-RN is administered through com- puterized adaptive testing (CAT). Candidates must register to take the examination at an approved testing center in their area. Because of a large test bank, CAT permits a variety of questions to be administered to a group of candidates. Candidates taking the examination at the same time may not necessarily receive the same questions. Once a can- didate answers a question, the computer analyzes the response and then chooses an appropriate ques-

tion to ask next. If the question was answered cor- rectly, the following question may be more difficult; if the question was answered incorrectly, the next question may be easier.

In April 2013 the new test plan was imple- mented. Changes in the test plan were based on the Findings from the 2011 RN Practice Analysis: Linking the NCLEX Examination to Practice (NCSBN, 2012). The minimum number of questions any can- didate may receive is 75, and the maximum is 265. Although the maximum amount of time for taking the examination is 6 hours, candidates who do well or those who are not performing well may finish as soon as 1 hour. The test ends once the analysis of the examination clearly determines that the candi- date has successfully passed, has undoubtedly failed, has answered the maximum number of questions, or has reached the time limit (NCSBN, 2012). The computer scores the test at the time it is taken; however, candidates are not notified of their status at the time of completion. The infor mation first goes to the testing service, which in turn notifies the appropriate state board. The state board notifies the candidate of the examination results.

Nursing practice requires the application of knowledge, skills, and abilities (NCSBN, 2012). The items are written to reflect the levels of Bloom’s taxonomy and are organized around client needs to reflect the candidates’ ability to make nursing deci- sions regarding client care through application and analysis of information. The examination is orga- nized into four major client need categories. Two of these categories, safe and effective care and physi- ological needs, include subdivisions (NCSBN, 2012). Integrated processes incorporate “nursing process, caring, communication and documen- tation and teaching/learning” (NCSBN, 2012, p. 3). Table 3-2 summarizes the categories and subcategories.

table 3-2

Major Categories and Subcategories of Client Needs Category Subcategories

Safe Effective Care Environment Management of Care Safety and Infection Control Health Promotion and Maintenance Basic Care and Comfort Psychosocial Integrity Pharmacological and Parenteral Therapies Physiological Integrity Reduction of Risk Potential

Physiological Adaptation

Source: Adapted from NCSBN NCLEX-RN test plan (NCSBN, 2007, pp. 3–4.)

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chapter 3 ■ Nursing Practice and the Law 43 Earlier, all questions were written in a multiple-

choice format. In 2003, alternative formats were introduced. These alternative-format questions include fill-in-the-blank; multiple-response an- swers; audio and video type; “hot spots” that re- quire the candidate to identify an area on a picture, graph, or chart; and drag-and-drop (NCSBN, 2012). More information on alternative formats can be found on the NCSBN Web site: www .ncsbn.org.

Preparing for the NCLEX-RN There are several ways to prepare for the NCLEX- RN. Some candidates attend review courses, others view videos and DVDs, and others review books. These methods assist in reviewing information that was learned during the classroom education. Each individual needs to decide what works best for him or her. It is helpful to take practice tests, because it familiarizes one with the computer and the exami- nation format. The NCSBN offers an online NCLEX-RN study program.

To prepare for the NCLEX, take time to look at the test blueprint provided by the NCSBN. This gives candidates a comprehensive overview of the types of questions to expect on the examination. Candidates can review alternative test formats by accessing www.pearsonvue.com/nclex/. Some test- taking tips follow.

■ Be positive. Remind yourself that you worked hard to reach this milestone and how prepared you are to take the licensure examination.

■ Turn negative thoughts into positive ones. Rather than saying, “I hope I pass,” tell yourself, “I know I will do well.”

■ Acknowledge your feelings regarding the NCLEX. It is fine to admit that you are anxious; however, use your positive thoughts to control the anxiety.

■ Also use diaphragmatic breathing (deep breathing) to control anxiety. Deep breathing augments the relaxation response of the body. Use this method at the beginning of the test or if you encounter a question that you find confusing.

■ Control the situation by making a list of the items you may need to take the test. Pack them in a bag several days before, and keep them in a place where you will remember to take them.

■ Eat well and get a good night’s sleep before the test. Avoid foods high in sugar and caffeine. Contrary to popular belief, caffeine interferes with your ability to concentrate. Eat complex carbohydrates and protein to maintain your blood glucose level.

■ Several days before you are scheduled to take the test, travel to the test site along the same route at the time you plan to go. Have an alternate itinerary in case there is a disruption in your route. This will alleviate any unnecessary stress in arriving at the examination site.

■ Leave early and give yourself plenty of time to get to your destination. Arriving early also gives you a sense of control.

■ Finally, remember your own basic needs. Testing centers tend to be cold. Pack a jacket or sweater. Check with the testing center to see if you are allowed to bring water or snacks.

Licensure Through Endorsement Nurses licensed in one state may obtain a license in another state through the process of endorsement. Each application is considered independently and is granted a license based on the rules and regula- tions of the state.

States differ in the number of continuing educa- tion credits required, legal requirements, and other educational requirements. Some states require that nurses meet the current criteria for licensure at the time of application, whereas others may grant the license based on the criteria in effect at the time of the original licensure (Ellis & Hartley, 2004). When applying for a license through endorsement, a nurse should always contact the board of nursing for the state and find out the exact requirements for licensure. This information can usually be found on the board of nursing Web site for that particular state.

Multistate Licensure The concept of multistate licensure allows a nurse licensed in one state to practice in additional states without obtaining additional licenses. NCSBN created a Multistate Licensure Compact, now referred to as the Nurse Licensure Compact, that permits this practice. States that belong to the compact have passed legislation adopting the terms of this agreement and are known as party states (https://www.ncsbn.org/nlc.htm). The nurse’s home

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44 unit 1 ■ Professional Considerations

state is the state where he or she lives and received his or her original license. Renewal of the license is completed in the home state.

A nurse can hold only one home-state license. If the nurse moves to another state that belongs to the compact, the nurse applies for licensure within that state based on residency. The nurse is expected to follow the guidelines for nursing practice for that new state. The multistate licensure applies only to a basic registered nurse license, not to advanced practice. More information on multistate licensure can be found on the NCSBN Web site.

Disciplinary Action State boards of nursing maintain rules and regula- tions for the practice of nursing. These may be found in the state’s nurse practice acts. Violation of these regulations results in disciplinary actions as delineated by these boards. Issues of primary con- cern include but are not limited to the following:

■ Falsifying documents to obtain a license ■ Being convicted of a felony ■ Practicing while under the influence of drugs

or alcohol ■ Functioning outside the scope of practice ■ Engaging in child or elder abuse

Nurses convicted of a felony or found guilty in a malpractice action may find themselves before their

state board of nursing or, in Canada, the provincial or territorial regulatory body.

Disciplinary action may include but is not limited to the suspension or revocation of a nursing license, mandatory fines, and mandatory continu- ing education. For more information regarding the regulations that guide nursing practice, consult the board of nursing in your state or, in Canad

 
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