Stop Nursing Violence

This is such an important issue that I am posting it on each of my blogs. Go to my "A Nurse Attorney's Thoughts" to read my post on horizontal violence where I discuss "nurses eat their young."

Changes for the Texas BON

This was sent by the Board to the Workforce Commission:

BOARD OF NURSE EXAMINERS
Fiscal Year 2007-2011 Workforce Plan

D. Anticipated Changes to the Mission, Strategies and Goals over the
next Five Years
The BNE is currently under Sunset Review in this biennium. We anticipate
changes in our mission to include regulating Certified Nurse Aides. We also
anticipate moving towards a “semi-independent” agency status. We see
changes in how we approve nursing schools by increased reliance on outside
accrediting entities. We have implemented some strategies to go “paperless” by
using available technology and plan to implement additional strategies in the
future. We anticipate the continuing education process to evolve into a
continued competency model to include portfolios and practice targeted
requirements.


I do not know what "semi-independent" agency status means, but I thought it was interesting that there is a plan to regulate CNAs. I am worried about the continuing education plans because I have heard complaints from nurses in other states that have practice requirements. I do not know what "portfolios" means.

What do you think?

Emails and employers

Be very careful what you put in an email (or an online posting for that matter). Remember that anything you put in writing can have the potential to harm you. Here is a recent case that should even drive that home more:

In Scott v. Beth Israel Medical Center, Inc., 2007 WL 3053351 (N.Y. Sup. Ct.
October 17, 2007), the court held that e-mail messages between the plaintiff
and his personal counsel were not privileged because the client's e-mails
were all sent thru his employer's server and the employer's e-mail policy
stated clearly: (i) its e-mail system should be used for business purposes
only; (ii) all communications over the hospital's system were the hospital's
property; (iii) no employee had a right of privacy w/ respect to messages
sent or received over the hospital's systems; and (iv) the hospital reserved
the right to access and disclose such communications at any time w/o prior
notice. The court cited In re Asia Global Crossing Ltd., 322 B.R. 247
(S.D.NY 2005) and Long v. Marubeni America Corp., 2006 WL 2998671 (S.D. NY
October 29, 2006). The court in Long reached the same result on similar
facts. The court in Asia Global Crossing did not find a waiver of privilege
because the substance of the employer's policies and the extent that the
employer's policies had been made known to employees were disputed.

Do patients really know about themselves?

I was sitting in a patient waiting room today and overheard one patient ask the person with them, "What is that medicine I am allergic to?" The two then proceeded to try to remember which medication it was and listening to them was frightening. The lack of knowledge about something so important serves as a reminder to caregivers:

Be sure to stress the importance to patients that they keep a list of allergies in their wallet and that it applies to any allergy, not just medication.

Question patients carefully regarding allergies and the reactions experienced to the allergic incidents. And document everything.

Peer Review Rules - Pay Attention

The Board of Nursing has proposed new rules concerning Peer Review in Texas. Be sure to read these today and if you disagree or agree with any of the proposed rules, send a comment immediately to the Board and contact your nursing organization and let them know your thoughts. These rules have the potential to affect your license, so do not sit by and be uninformed.

Stay Informed

Be sure to read my post about what is happening at the Medical Board because it might affect the Texas Nursing Board.

The Questions the BON Asks

The Texas Board of Nursing has changed their questions on licensure renewals and applications for licensure. For renewals, they stopped asking if a nurse has "ever" been convicted...and now ask if a criminal action has taken place within the past 24 months or since the last renewal. For both renewals and applications, the Board has phrased the question in bullet point format. They included military actions and a broad question about being "cited or charged with any violation of the law."

The Board finally quit asking nurses to disclose expunged and sealed offenses, but they are putting the burden on nurses to ensure that the criminal activity has truly been expunged. This is a big problem in that people are frequently told their criminal history has been expunged when in fact, it has not. So, be sure that you have proof of the expungement in the form of a copy of the Court Order expunging and/or sealing the offense(s). The Board recommends that a nurse provide a copy of this Court Order along with your renewal or application. However, they do not require it. So, before providing expunged or sealed information to the Board, it would be prudent to discuss the matter with an attorney to determine whether just having a copy of the Court Order is enough and that you do not need to provide that copy to the Board.

The Board has also added a question about whether the nurse is "currently the target or subject of a grand jury or governmental agency investigation." Remember to read the questions very carefully and seek legal advice when there are any questions. The Board considers non-disclosure, even when done in error, to be potential deception and subject to action.

Think For Yourself and Question All

I was driving home last night listening to a talk radio show. On the show the host was discussing whether a woman that had a mastectomy due to a misdiagnoses should be allowed to sue the doctor for a simple error. The host continued his discussion stating that simple errors should not be cause for litigation and that since the doctor did not intend to misdiagnose the woman, the doctor should not be sued. The host was getting very animated with each caller, discussing how he never sues anyone and that we are all litigation happy. The various callers were discussing how they would either only give the woman the cost of a "boob job" or give her nothing. The host was using all of this to continue to project how we need reforms and that lawsuits cost us all. He would spend a great deal of time with the callers that were agreeing with his premise of too many lawsuits, continuing to ask them questions to draw out more discussion about how this woman deserved no or little money.

I had heard the woman earlier that day describing what had happened and knew that the talk show host had key facts wrong. I called in and waited to talk to the host.
Since there had been discussion about the most this woman should expect to compensated was for the cost of a simple "boob job," I felt compelled when I FINALLY got on the air to discuss this misconception. I explained that the woman was facing extensive reconstructive surgery , not a simple breast enlargement and that her breasts would never be the same as they were before. I explained that women can have significant complications after reconstructive surgery so there was nothing simple about it.

I then proceeded to tell the host that this was not a simple error involving a doctor, instead it was a lab cutting corners and performing multiple tests at once to save money. And that due to the cutting corners, two women have been injured - the one who had the mastectomy and did not have cancer and the woman who did have cancer and has gone untreated for many months. The host then made a statement that surely I was in favor of cutting costs. When I replied, No, not when it ends up inflicting damage on people and I also added that there are continued cost cutting even when the corporate revenues are up and that patients are the ones being harmed and they have no recourse in many situations, but I was hung up on so that it seemed that my last statement was No, not when it ends up inflicting damage on people.

So, the radio station/host was editing people's comments to promote their agenda of too many lawsuits. Instead of allowing me to discuss the issue completely, they hung up on my call. I continued to listen and noticed that I could often pick out exactly when they hung up on other callers that disagreed with the host.

I thought here is another example of how the media is crafting what we hear and see to lead us to their ideas. They are not interested in the truth, but rather what makes better entertainment. I have been present when a person was interviewed for a story, yet when I watch the interview on TV the context is vastly different than what the reality was.

Once again, as nurses you have a scientific mind and you should utilize that mind to question what you are told and shown. Be an individual and investigate the truth. Make up your own minds and take action based on what you know to be right. Others are looking to you to be a leader or at least completely informed. Just because a co-worker, or administrator, or physician or a talk show host tells you something, you must decide for yourself what is correct. If you do not have enough information to determine what is the truth, investigate it until you are an informed nurse.

Just my thoughts, you can disagree, but then again that is the point--question and think for yourself!

Diaster Planning

I just saw an ad on TV for people to learn about disaster planning for an pandemic. So, my question of the day for nurses - Are you prepared in case of a disaster? I don't mean if your employer has a disaster plan (let's hope they do). I am asking if you have a disaster plan for you and your family. Nurses are going to be heavily relied upon if a disaster strikes and you must be prepared on the home front. If you are tied up assisting, what is your family going to do? Do you have enough food, water? Do you have a communication plan? Will you have to go in to work or report to a regional site? Who will watch your kids? Is your spouse/significant other aware of the plan? What if you have to evacuate your family? your pets?

There are multiple sites with checklists that help to address these issues and help with planning. Be sure to do this today. And while you are at it, don't forget to draft a will.

Can TPAPN Help?

Frequently, I get inquires from nurses that have been referred to TPAPN (Texas Peer Assistance Program for Nurses) and the nurse was wondering if they should go to TPAPN. If a nurse has substance abuse/addiction issue or mental health issues, TPAPN can be a beneficial rung on the ladder to recovery or health and the nurse should definitely consider entering the program. TPAPN offers not only recovery support, but also the ability to avoid a disciplinary action by the Board.

But, if a nurse is thinking of going to TPAPN solely to avoid being reported to the Board, the nurse should know this is risky and frequently backfires. Several steps in the TPAPN process require a nurse to admit to being an addict or alcoholic and to continue to do this when a nurse is not; it begins to wear on the nurse (especially with the emphasis on truth and accountability in the recovery process). Also, once a nurse admits to a problem it is very difficult to back track and declare there is now no problem. I have heard from nurses that have come close to completion of the TPAPN contract and then decided they can’t “live the lie” anymore and they announce they are not an addict and don’t belong in TPAPN. If this nurse was a third-party referral, TPAPN must report the nurse to the Board, which puts the nurse right back where they started.

How to Find a Nurse Attorney

I often get inquires from nurses in other states looking for an attorney to represent them before their state’s nursing board. Since I can only represent nurses before the Texas Board of Nursing I wanted to give some hints for nurses to find an attorney in their state. The area of law involved is Administrative Law, so you want to look for an administrative lawyer, not a family law lawyer, not a criminal defense attorney, not a medical malpractice attorney, and on and on. Look for recommendations from –

· State nursing association
· The American Association of Nurse Attorneys referral line (1-866-807-7133)
· State Bar
· co-workers, supervisors (if appropriate)
· sometimes even the Nursing Board will provide names of attorneys that frequently practice before them

Search
· online
· yellow pages (although most attorneys seem to be placing their advertising money into internet advertising)
· professional journals
· articles

Jurisprudence (Nursing Law ) Seminars

I am going to be speaking at the San Antonio Advance for Nurses Job Fair. I am thrilled to be able to speak before the nurses attending the job fair, but I find these frustrating because I only have an hour and there is SO MUCH I want to tell nurses. When I give seminars, I spend 6-8 hours cramming in all the information nurses need to know (not dry, I include lots of humor and interesting facts to keep you interested).

I have been asked when are my next seminars. The problem is that too many of you are getting your CUEs online or by mail and the demand for speakers to give in person seminars has diminished. I am looking for a seminar company that is still providing in person seminars and occasionally, hospitals hire me to come speak to their nurses, but so far no seminars are scheduled. I am finishing up my book and looking for a publisher, so that may be the only way to get all the information out to nurses. Thanks for all your inquiries.

Careful Advance Practice Nurses

I just heard from another APN that was about to accept a position and was relying upon the assurances of the agency/employer that was offering the position and the assurances were incorrect. It is your license, so you have to know the laws and requirements for practice. Do not rely upon someone else's assurances. Also, be sure that you check all paperwork because if there is an error, you are the one in trouble.

APNs tend to get in trouble over paperwork issues, not patient care issues. It is extremely heartbreaking to have a nurse in trouble for signing a paper they did not review closely or for following the recommendations of an administrator at an agency.

Watch out when renewing your license

Be sure to watch for when it is getting close to your renewal period for renewing your license. The Board is getting fingerprints on every licensed nurse that has not already submitted fingerprints and they are also conducting CEU audits. So, if you wait until a couple of weeks prior to the end of your renewal period, you might find yourself without an active license to practice with. And do not be fooled by the Board's wording about "delinquent" licenses, if you do not have an active license, you can not work as a nurse. There is no grace period while your license is delinquent.

So, play it safe and renew 2 months prior to the end of your renewal period.

Laugh a Little

Here is a little humor for the day:

Hospital regulations require a wheel chair for patients being discharged. However, while working as a student nurse, I found one elderly gentleman already dressed and sitting on the bed with a suitcase at his feet, who insisted he! didn't need my help to leave the hospital.
After a chat about rules being rules, he reluctantly let me wheel him to the elevator.
On the way down I asked him if his wife was meeting him.
"I don't know," he said. "She's still upstairs in the bathroom changing out of her hospital gown."

Sicko

Don't forget that Sicko, Michael Moore's look into healthcare in America hits the screens this weekend. So far the ratings have been good by film reviewers, but there is another take on NursingLink.com. So, it seems the answer will be to see for yourself.

The Nurse's Chapel

Go have a look at the blog "Running with Scissors". There are some incredible pictures shown on the blog that were taken inside the Nurse's Chapel in Westminster Abbey.

Continuing Education Changes

The Board has posted new proposed rule changes to section 216 "Continuing Education". The Board used to audit the CEUs for randomly selected nurses and if they were found to be lacking the required number of hours, an investigation was opened and disciplinary action taken, which might eventually result in suspension of the nurse's license. The new rules will have the Board doing random audits, but if the nurse is non compliant the nurse's license will not be renewed. This makes the process of stopping the nurse from practice much quicker. The nurse can still be investigated and additional disciplinary action taken. Then, if a nurse is found non-compliant and does not get renewed the very next renewal period the same nurse will also be subject to an audit.

I really dislike this rule because it takes nurses out of practice for something as simple as not enough CEUs or not responding to the Board (another reason to be sure that your address is kept current with the Board) when audited. CEUs are not a way to maintain competency, as anyone who has done a home study or online study knows and to use CEUs like this does not appear to be a good use of regulatory power.

Texas nurses need to join nursing associations and fight rules like this!

No more Texas Board of Nurse Examiners

Okay, I know that title got you riled up or maybe excited or maybe worried, but it is true. This legislative session produced legislation that will change the name of the Texas Board of Nurse Examiners to the Texas Board of Nursing. This is one of the changes requested by the Board during the Sunset Advisory Commission's review of the agency last year. Continue to watch here for updates on the changes to nursing from the new laws.

Changes Coming

The Star-Telegram published an article about the Board of Nursing in Texas. The article details the Board's reputation for being the most aggressive Board in Texas and at the forefront of nursing regulation in the country.

Nurses in other states should watch Texas because Texas seems to be the pioneer for nursing regulatory agencies in that they are usually one of the first states to initiate various regulatory actions. For example, nurses in other states should watch for criminal background checks for ALL licensed nurses to come to their state. Texas has been doing this for a few years; all nurses that are actively licensed are requested to provide fingerprints and if a background check shows an undisclosed criminal action, the nurse is subject to investigation and possible discipline.

For a long time I have cautioned Texas nurses that the Board of Nursing may follow what the Medical Board has been doing and this article confirms that the changes are coming: The board lists the names of nurses that have been disciplined along with which sections of the law the nurse violated. The article interviewed Board Staff and reported that "in the next few months, it will beef up that portion of the site to give detailed information about specific violations."

Clarification on Process at BNE

I just got back to my office after representing a individual applying for a license in Texas at the BNE. While there, some of the nurses were discussing what they thought the process would be like when they spoke to the Board. They all thought that it would be in a court-like setting and that they would testify "on the stand" or behind a podium. Wanting to alleviate any stress caused by these perceptions, I explained that the Texas Board of Nurses holds their disciplinary proceedings (Informal Conferences)or Eligibility and Disciplinary Committee meetings in a conference room within the Board. The room is also a library so there are books lining the walls. There are two tables arranged in a "T" fashion in the middle of the room. The larger table is where the Board members/staff sit and the smaller conference table is where the applicant/licensee and his/her attorney sit. No one stands to speak and there are no courtroom type procedures. The Texas Board of Nurse Examiners have gone paperless, so they will utilize laptop computers during the proceedings.

Not even one drink...

I had posted this earlier on A Nurse Attorney's Thoughts, but because I am hearing from more nurses that have gotten themselves into trouble due to bad decisions while under the influence of alcohol, I am going to post the information here:

Do not take even one drink and drive because it is too costly: not only could you kill or harm yourself and others, but if you are arrested, you start down a course that can have extreme adverse results. DWIs/DUIs are expensive. A recent article in the Austin American-Statesman listed the various costs associated with a DWI. When I added up the high ranges for these costs it came to approximately $50,000 and that did not include recurrent costs such as drug screens. Then you are faced with the criminal repercussions. In addition, if you are licensed by a regulatory board, you will most likely be investigated for possible intemperate use.

For example, a nurse accused of intemperate use must prove his or her sobriety (the DWI or positive urine screen is used by the Board as evidence of the substance abuse). It takes a lot of time and money and produces quite a bit of stress to prove one's sobriety.

It is so much easier and cheaper to just pay for a taxi or have a true designated driver. Also, these decisions must be made prior to engaging in drinking because once a person drinks, their decision-making can be impaired and they will think that they are fine to drive. I represent many health care providers that are accused of substance abuse/addiction and they will agree - Not even one drink if you are going to drive!

Documentation Again

Documentation is so important for nurses that I think it is important to share this post from Texas Nursing Documentation:

Who Cares About Documentation

Who Cares About Documentation? Nurses had better care and take action. Documentation is required as part of the nursing process. Documentation is not just some tedious task that can wait till the end of the day. A lack of documentation or inadequate documentation lends creditability to the premise that the nursing care was not provided. Inadequate documentation is a violation of the Board's rules and regulations and it can seriously harm a nurse in lawsuits as well. I hear over and over from clients that they wished they had documented "such and such" and "If only I had documented, I would not be before the Board." Nurses must change their way of thinking and organize their workdays so that they can timely and adequately document.

Nurse Practitioners

Most of my clients that are nurse practitioners are in trouble before the Board of Nurses not because of patient care issues, but rather because of a failure to follow (and usually understand) the rules and regulations governing their nursing practice. It is crucial that nurse practitioners take a copy of the rules and regulations and use them as a check sheet. These rules apply even if a NP is only covering for a colleague.

The American Association of Nurse Attorneys has a book available regarding the law and nurse practitioners (click on marketplace, then on online store:TAANA products). I have not personally seen the book, but it may be worth looking into. It is also very important for NPs to be a member of nurse practitioner associations so that the NP will be informed of any new laws.

Nurses on TV

Just a quick note: I found a great discussion on the history of nurses on TV at Nurse Ratched's Place. It brought back great memories and I thought some of you might like to see it.

The Best Attorney for the Job

A previous post explained why nurses should never represent themselves before the Board of Nurses and that they should hire the best attorney available. Now, what is meant by "the best attorney?" Whenever hiring an attorney for any legal work (Board, malpractice defense, real estate, family law etc.), a person should look for an attorney that is knowledgeable and experienced in the particular area of law involved.

Board Certification in the particular area is a good indicator of experience and knowledge. However, when it comes to representation before regulatory boards, it is important to inquire as to whether the lawyer has experience before that particular board and how much experience (how many years have they been practicing before the Board, how many of their clients are nurses). Success with administrative boards often depends on knowing the staff, the policies, and their usual methods.

Be sure to talk to the attorney you are thinking of hiring. Do they return your calls or emails? Do you only get to speak to their secretary or assistant? Do they seem to know the law involved or do they always tell you that they will have to "research" a particular issue? Do they seem to know the people that work at a Board and the ways in which the Board functions? You may want to speak to 2-3 different attorneys because everybody has a different personality and approach to practice. The key is that you want to be able to trust your attorney and have confidence in their representation of you. Because you will be working together for a while, you should also like your attorney and feel comfortable with them.

Hint: Cost is no indication of quality. Attorneys charge different fees based on their experience, education, certifications, overhead and caseload. A good lawyer could be expensive, moderate or inexpensive. The key is to find someone that meets your needs, that is experienced, and knowledgeable. But above all -- DO NOT REPRESENT YOURSELF!

There are some areas of caution to be aware of:
I received several phone calls last year from an attorney Board Certified in Administrative Law (the type of law involving regulatory boards) asking questions about the Board of Nurses and how they functioned. Although this attorney was Board Certified in the particular area of law, he stated that he dealt with real estate and did not have any experience before the Board of Nurses. He was calling for a friend that needed representation before the Board and he was going to refer him to me once he convinced the friend to hire an attorney. The friend never contacted me and now this same attorney is advertising that he is a specialist in occupational licensing defense.

With tort reform changes, there have been many attorneys leaving or branching out from malpractice defense work. Several of these attorneys are looking to administrative law as a new practice area. These may not the best attorneys to choose because of their perceived lack of knowledge and experience before the Board. The only way to determine, is to talk to whomever you are thinking of hiring and decide if this is the attorney you want to hire.

Representing Yourself Before the Board of Nurses

I heard from a nurse who is facing possible action before the Board. She had asked a nurse friend about hiring an attorney and was told that the Board of Nurses is nothing to worry about, that they will understand what happened and because she is a good nurse nothing will result from the complaint. A quick look at the newsletter shows that this is not true. Many "good" nurses receive disciplinary action by the Board. Some of those actions were not deserved and some may have received harsher restrictions than what was warranted. How can this happen?

The Board's mission is to protect the public, not the nurse. For more on this read "The Nurse Police." Since the Board is not responsible for protecting the nurse, they are interested in resolving complaints against nurses in the fastest way that also protects the public. The Board is not in a position to tell nurses the best ways to defend themselves. The Board is not the nurse's friend, that is not their role. So, who is available to advocate for and protect the nurse? Administrative Law Attorneys with experience before the Board of Nurses.

Nurses that would never think of representing themselves in a malpractice lawsuit will think nothing of going on their own before the Board of Nurses. While a lawsuit can cost you money, losing with the Board can cost your career. There is also the issue of time and knowledge. Nurses are busy working, taking care of their families, and living their lives, they do not have the time to learn administrative law (the type of law involved with regulatory agencies) and to deal with the Board. I attend many hours of continuing education a year in order to remain current with Administrative Law issues and there are even attorneys that cannot keep up with the changes in all the areas of law, so how can a nurse be expected to have the time? A survey was conducted with nurses that had been through disciplinary actions and they highly recommended that nurses not represent themselves and that they spare no expense in hiring the best attorney. Many of my clients are nurses that are under their second investigation and because of the problems they encountered with the first investigation, they decided that they learned from the first time and that it was in their best interest to hire an attorney this time.

Coming next: What is the "best attorney"?

Documentation Issues

I received a phone call from a nurse that had been told that it was against the law to use other staff members' names in nursing notes. This is not true. It is preferable to use other staff members' names in addition to their title so that it is clear which staff member was involved. For example: instead of "I reported the low BP to the charge nurse" document "I reported the low BP to charge nurse Ned Nurse."

Remember that staffing records and other administrative records can disappear and the documentation may be the only record of which supervisor, co-worker, doctor the nurse spoke with. Good documentation is a Good Defense. For more information about the law and documentation see Who Cares About Documentation?

Bad checks and nursing

Did you realize that writing bad checks can be used against your nursing career? Many people that write bad checks never make the connection that "hot" checks are theft. Theft is a concern for the Board of Nurses because of the trust position nurses are put in and their frequent access to patient's belongings. This is not to state that just one bad check will result in Board action, but theft by check can come under Board scrutiny.

There are no "innocent" crimes. Any crime can invite Board review. When I was working for the Physician Assistant Board (while at the Texas Medical Board), there was an applicant for licensure that had been convicted of shoplifting. He had changed the price on a pair of jeans and was caught, arrested and convicted. He had to appear before the PA Board to explain why he had attempted to steal from that business and then to justify why he still should be allowed to become a PA in Texas.

Online Newsletter Better?

All Texas Nurses should review the Board's newsletter both online and the copy they get in the mail. Many times, the newsletter online contains more information in that articles are promptly made available online but are delayed in being published in the hard copy. For example, the article regarding prescription medications that was discussed in a earlier blog is currently available in the April 2007 newsletter, but it will not come out in print form until the July 2007 newsletter.

What? you say you don't read the newsletter except to see who got in trouble!!! (look for a post on this located at a Nurse Attorney's Thoughts) All nurses as professionals are required to be informed about their profession. The newsletter is the method that the Nursing Board chooses to inform nurses about changes in the laws governing their practice. But,if you don't read it, you are ignorant and Ignorance of the Law is NO Defense. So, take the time and become informed - read your newsletter.

When Moving Causes Problems

Several nurses have found themselves at the receiving end of an investigation because they did not notify the Board of Nurses when they changed their address. As a licensed professional, a nurse must keep the Board informed of where the nurse is located. In Texas, a nurse has 10 days to notify the Board of Nursing of an address change. The Board might contact a licensee for random audits of continuing education or for criminal background checks or even for an investigation into a complaint. If the Board cannot notify the licensee, the proceedings continue without the nurse. In other words, the game continues even if the nurse is not there to play defense.

So, when moving be sure to notify the Board of your new address at the same time you set up your utilities. It is a small thing that is often overlooked, but the consequences can be huge.

Are you a Nurse or Dr?

Nurses can perform tasks that are within their scope of practice. If the tasks involves a medical act, then there must be an order for that task. Nurses sometimes do not realize these boundaries and can find themselves accused of practicing medicine by stepping beyond their scope.

A common example of this is when a nurse is working a night shift and a patient needs Tylenol or an antiemetic. The nurse decides not to wake the physician and goes ahead and writes a telephone order for the medication and administers the medication. The nurse justifies the action by deciding that the physician will cover the nurse with an order in the morning or will sign the telephone order in the morning. By doing these actions the nurse has practiced medicine and committed fraud by documenting a telephone order that never took place. Harm has resulted to patients by the administration of "simple" medications by nurses who were not aware of the treatment plan or that did not understand the patient's disease process or all aspects of the medication. Physicians are understandably upset at being held responsible for an order they did not give and they are speaking up and reporting nurses.

There must always be an order for a medical task. Orders are not required for nursing tasks because those are within a nurse's scope of practice as determined by licensure. If a nurse cannot get assistance for a patient from a physician, the nurse should not assume the role of the physician, but should take the issue up the chain of command until the proper result is obtained for the patient.

Sepsis

There is a surge of lawsuits involving infections, particularly the failure to recognize signs and symptoms of sepsis. Patients are dying and when the records are reviewed classic signs and symptoms of sepsis are shown in the records. Also remember that the elderly can present special problems when doing assessments and trying to determine the cause of their presentation.

Some of the signs and symptoms: Fever may be present or the patient may have a low body temperature; increased ventilation, confusion or altered mental status (this is causing a problem with the elderly because instead of recognizing sepsis, the health care provider assumes the confusion is due to old age or other mental illnesses), increased heart rate, decreased urine output, may have chills, shaking, rash. When these symptoms present, laboratory tests need to be conducted to protect the patient.

Remember that any changes in a patient's presentation requires a re-assessment and intervention and then documentation of those actions.

Working while taking pain medication

In the April 2007 Board of Nurses' newsletter (www.bne.state.tx.us), there is an article that every nurse should read, "Prescription Pain Medication Usage by the Practicing Nurse". A nurse never knows when this issue may come up in his or her personal life and practice and it is a benefit to know the Board's stance on this issue. If a nurse is in management, the article is must read right now. The key is that the medication is prescribed for the ailment that the nurse is taking it for (so, no borrowing of medications from friends or family and no taking a pain medication prescribed for a root canal to treat a hurt back and NO illegal drugs). The nurse also has to stay within the prescribed dosage levels. The newsletter can be found on the Board's website under Publications.

Nurses Beware

As the Legislative Session winds down, Texas Nurses need to watch for new laws impacting nursing practice. Because of the often rapidly changing legal environment, nurses should be a member of a state nursing association (either general such as TNA or practice specific) so that nurses can be kept abreast of new law, rules or regulations or of attempts to alter nursing practice.

This Legislative Session contained many laws impacting nursing practice and many look like they will pass and become law.

Board withdraws position statement

The Texas Nursing Board met on April 18, 2007 and due to overwhelming comments received, decided to withdraw the proposed position statement on working hours and send it back to the Nursing Practice Advisory Committee for review and revision. There is more detailed information available in the April 2007 newsletter and on the Board's website www.bne.state.tx.us under "Nursing Practice".

Texas BON's Position Statement on Work Hours

The Texas Board of Nurses has drafted a new position statement on the hours nurses should work. This statement was drafted to address the problem of nurses working excessive hours and the impact that has on patient safety. Go to the board's website at www.bne.state.tx.us or look in the January newsletter to access further information on the proposed statement. I hear frequently from nurses that are being forced to work more hours that they believe are safe and they fear termination if they refuse to work. This proposed statement will help to address those problems by giving support to the nurses.

Whenever I hear about excessive work hours for nurses, I am reminded of a student nurse that told me at a seminar that when he graduated, he planned to work 12 hours at one facility and then go across the street and work an additional shift of 8-10 hours!!! at another facility in order to make lots of money. He said that he was able to function quite well without much sleep and since there was no restriction on the amount of hours, he could work as long as he wanted to. He ignored the requirement that a nurse must be fit to accept an assignment because he said that whether he was fit or not did not depend on the number of hours he had been awake. He would not give me his name and he ignored any attempts to convince him of the potential danger. As I think about him, I hope that the reality of nursing kept him from fulfilling his plan.

On their website, the Texas BON has other position statements and guidelines to assist nurses and employers with understanding the practice requirements placed on GNs, LVNs, and RNs. Also, check my website for additional helpful articles at www.healthlicensedefense.com