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".