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CHANCE OF SURVIVAL DIMINISHED On the afternoon of May 20, the patient, Mr. Ard, began feeling nauseated. He was in pain and had shortness of bre


CHANCE OF SURVIVAL DIMINISHED On the afternoon of May 20, the patient, Mr. Ard, began feeling nauseated. He was in pain and had shortness of bre



On the afternoon of May 20, the patient, Mr. Ard, began feeling nauseated. He was in pain and had shortness of breath. Although his wife rang the call bell several times, it was not until sometime later that evening that someone responded and gave Ard medication for the nausea. The nausea continued to worsen. Mrs. Ard then noticed that her husband was having difficulty breathing. He was reeling from side to side in bed. Believing that her husband was dying, she continued to call for help. She estimated that she rang the call bell for 1.25 hours before anyone responded. A code was eventually called. Unfortunately, Mr. Ard did not survive the code. There was no documentation in the medical records for May 20, between 5:30 PM and 6:45 PM, that would indicate that any nurse or physician checked on Ard’s condition. This finding collaborated Mrs. Ard’s testimony regarding this time period.

A wrongful death action was brought against the hospital, and the district court granted judgment for Mrs. Ard. The hospital appealed.

Ms. Krebs, an expert in general nursing, stated that it should have been obvious to the nurses from the physicians’ progress notes that the patient was a high risk for aspiration. This problem was never addressed in the nurses’ care plan or in the nurses’ notes.

On May 20, Ard’s assigned nurse was Ms. Florscheim. Krebs stated that Florscheim did not perform a full assessment of the patient’s respiratory and lung status. There was nothing in the record indicating that she completed such an evaluation after he vomited. Krebs also testified that a nurse did not conduct a swallowing assessment at any time. Although Florscheim testified that she checked on the patient around 6:00 PM on May 20, there was no documentation in the medical record. Ms. Farris, an expert witness for the defense, testified on cross-examination that if a patient was in the type of distress described by Mrs. Ard and no nurse checked on him for 1.25 hours, that would fall below the expected standard of care.1


  1. What happened?
  2. Why did things go wrong?
  3. What were the relevant legal issues?
  4. How could the event have been prevented?
  5. What is your verdict?


he similarities and differences between the American legal system and the legal structure of health care organizations.

Regarding the American legal system and health care organizational legal structures, there are a multitude of similarities and differences. Both systems implement a degree of liability in the sense of governing bodies designed to facilitate the “agreed upon actions,” laws given a specified situation. As Miller cites (2006), “government is divided into three branches, legislative, executive, and judicial. On the federal level, statutes are enacted by Congress and only become law when approved by the president” (p.4). However, a particular bill can be over-ruled and disallowed by the Supreme Court of the United States. Miller adds (2006), “a method of overriding a Supreme Court decision, while complex and often time consuming, is to amend the Constitution” (p.4). Similarly, health care organizations implement governing boards, a group of individuals designed to regulate, instill, and facilitate specified laws and by-laws regarding the organization in question. Miller explains (2006), “almost all health care is delivered within an organized system. Clinical and regulatory complexity requires an infrastructure that can be provided only by a well-ordered structure. The organization of most health care entities, regardless of their type, includes a governing body and a chief executive officer” (p.29). Another interesting similarity exists between the American legal system and the legal structure of health care organizations. Both systems must comply with the specified laws imposed by the U.S. President, Congress, and the Supreme Court. A prime example would be the enactment of the laws governing workman’s compensation allocation and the unemployment benefits act for all workers.

A subsequent and primary difference between the American legal system and the health care organizational legal structures centers on bylaws. For-profit organizations incorporate bylaws into policies and procedures and any changes are generally related to the workforce via addendums within the organizational personnel employee handbook. Interestingly, regarding the Long-Term care industry, specific laws governing the care of residents become enacted through federal and state mandates, such laws are enforced by federal and state agencies and must be followed by the individual Long-Term care facilities; however, the Long-Term care organizations cannot change such laws, policies, and procedures. Yet, the federal and state agencies can and do change these laws according to statistical incidence such as falls rates, medication errors, and reluctance to comply pertaining to yearly facility inspections. Another poignant and specific difference relates to appointment vs. election. Miller cites (2006), “health care entities ultimate responsibility centers on establishing goals and polices, select the chief executive, and appoint medical staff members” (p.30). Within the American legal system, the chief executive leaders are elected and maintain their position through the process of re-election.

Lastly, the monetary acquisition of funds regarding the for-profit organizations centers on investors, multiple corporations, and stakeholders/ stocks. However, federal organizations are funded through taxation of its citizenry. Interestingly, there are in place a great deal of federal and state regulations regarding the offering, sale, and re-sale of company stock and partnership interests. Wolper (2004) suggests that, “historically, the legal structure of the health care delivery system in the United States consists almost exclusively of personal interactions between patients and physicians. Today, the health care delivery system is almost completely composed of corporate entities, many of which are investor owned” (p.93). Through similarities and differences of the American legal system and the health care organizational legal structures, it is interesting to view the justification of the intermingling and adaptation of principles that appear to be borrowed from the American legal system and incorporated into the health care organizational legal system. Yet, with this said, the federal government provides more than just structure for health care organizations, they implement a great deal of the mandated policies and procedures that must be followed with strict adherence, regardless of the health care organizations self-enacted laws, by-laws, polices, and procedures.


Miller, R. D. (2006). Problems in health care law. Sudbury, MA: Jones and Bartlett Publishers.

Wolper, L.F. (2004). Health Care Administration: planning, implementing, and managing organized delivery systems. Sudbury, MA: Jones and Bartlett Publishers.

Dr. Robert C. Smiles, Ph.D. Assistant Professor, University of Arizona Global Campus

Nursing and the Law


© Monkey Business Images/Shutterstock


It’s Your Gavel…


On the afternoon of May 20, the patient, Mr. Ard, began feeling nauseated. He was in pain and had shortness of breath. Although his wife rang the call bell several times, it was not until sometime later that evening that someone responded and gave Ard medication for the nausea. The nausea continued to worsen. Mrs. Ard then noticed that her husband was having difficulty breathing. He was reeling from side to side in bed. Believing that her husband was dying, she continued to call for help. She estimated that she rang the call bell for 1.25 hours before anyone responded. A code was eventually called. Unfortunately, Mr. Ard did not survive the code. There was no documentation in the medical records for May 20, between 5:30 PM and 6:45 PM, that would indicate that any nurse or physician checked on Ard’s condition. This finding collaborated Mrs. Ard’s testimony regarding this time period.

A wrongful death action was brought against the hospital, and the district court granted judgment for Mrs. Ard. The hospital appealed.

Ms. Krebs, an expert in general nursing, stated that it should have been obvious to the nurses from the physicians’ progress notes that the patient was a high risk for aspiration. This problem was never addressed in the nurses’ care plan or in the nurses’ notes.

On May 20, Ard’s assigned nurse was Ms. Florscheim. Krebs stated that Florscheim did not perform a full assessment of the patient’s respiratory and lung status. There was nothing in the record indicating that she completed such an evaluation after he vomited. Krebs also testified that a nurse did not conduct a swallowing assessment at any time. Although Florscheim testified that she checked on the patient around 6:00 PM on May 20, there was no documentation in the medical record. Ms. Farris, an expert witness for the defense, testified on cross-examination that if a patient was in the type of distress described by Mrs. Ard and no nurse checked on him for 1.25 hours, that would fall below the expected standard of care.1



To Be a Nurse: Swedish Hospital, Seattle, Washington

•  Nursing is the honor and privilege of caring for the needs of individuals in their time of need. The responsibility is one of growth to develop the mind, soul, and physical well-being of oneself as well as the one cared for.

•  In memory of all those patients that have enriched my life and blessed me with their spirit of living—while they are dying.

•  There are many things I love about being an RN, but as a Recovery Room nurse, my favorite, by far, is being able to tell a groggy but anxious patient, “It was benign.”

•  Excellence is about who we are, what we believe in, what we do with everyday of our lives. And in some ways we are a sum total of those who have loved us and those who we have given ourselves to.

•  I have been with a number of people/patients when they die and have stood in awe. Nursing encompasses the sublime and the dreaded. We are regularly expected to do the impossible. I feel honored to be in this profession.

•  To get well, I knew I had to accept the care and love that were given to me—when I did healing washed over me like water.

•  Through all of this I was never alone.

•  Thank you!

•  In the caring for one another, both are forever changed.

•  A friend takes your hand and touches your heart.

•  To all of you whose names were blurred by the pain and the drugs.

•  Don’t ever underestimate your role in getting patients back on their feet.

—Swedish Hospital, Seattle, Washington, Unknown Authors

Learning Objectives

The reader, upon completion of this chapter, will be able to:

•  Describe how the scope of nursing practice continues to evolve.

•  Describe common categories of nursing staff.

•  Explain the process of obtaining nurse licensure.

•  Describe a variety of the legal risks nurses encounter.

•  Describe the ways in which a nurse is a patient advocate.

This chapter provides an overview of nursing practice, nurse licensure, and various nursing specialties, as well as a review of cases focused on the legal risks of nurses. The cases presented highlight those areas in which nurses tend to be most vulnerable to lawsuits.


The role of the nurse continues to evolve and expand due to a shortage of primary care physicians in rural and inner-city areas, ever-increasing specialization, improved technology, public demand, and expectations within the profession itself. A nurse who exceeds his or her scope of practice as defined by applicable statutes (e.g., nurse practice acts) can be found to have violated licensure provisions and thus be subject to disciplinary action.

The following table describes several of the key historical events that have led to the continuing expansion of the roles and duties of nurses in patient care settings.

The expanding scope of nursing practice is accompanied by increased ethical and legal risks.

Nurses are at risk for inappropriate professional relationships due to the broadening scope of nursing practice amidst rapid societal changes and pressures. The complexities of professional nursing relationships have outpaced awareness of ethical considerations of boundary issues. In addition, because professional nursing is founded on a caring ethic and nurses become intimately involved in life experiences of clients and families, nurses may be at risk for confusion over boundaries and inappropriate relationships. Boundaries, which historically were unclear, are increasingly recognized as an issue for the profession.2


1901—New York began to organize for passage of nurse practice legislation.

1903—North Carolina enacted the first nurse registration act.

1905—The development of the hospital economics course at Teachers College, Columbia University, ushered in a new era in preparation of nurse leaders in America. This 1-year certificate course was extended to a 2-year post–basic training program in 1905. The commitment of key nursing leaders to advancing educational preparation for nurse faculty fostered the subsequent development of baccalaureate education in nursing during the first quarter of the 20th century.

1937—The American Nurses Association (ANA) began recommending that nurses use their professional organization to improve every phase of their working lives.

1938—New York enacted the first exclusive practice act. This act required mandatory licensure of everyone who performed nursing functions as a matter of employment.

1946—The ANA convention adopted an economic security program and called for collective action on such items as a 40-hour workweek and higher minimum wages.

1952—All states, including the District of Columbia and U.S. territories, had enacted nurse practice acts.

1955—The ANA approved a model definition for nursing practice.

1957—The California Nurses Association met with representatives of medical and hospital associations to draw up a statement supporting nurses in performing venous punctures.

1966—The Michigan Heart Association favored the use of defibrillators by coronary care nurses.

1968—The Hawaii nursing, medical, and hospital associations approved nurses performing cardiopulmonary resuscitation.

1970—The ANA amended its model definition for nursing practice to include nursing diagnosis.

1971—Idaho revised its nurse practice act by allowing diagnosis and treatment as part of the scope of practice for nurse practitioners (NPs).

1972—New York expanded its nurse practice act and adopted a broad definition of nursing.

1973—The first ANA guidelines for NPs were written for geriatric NPs. These were later modified and adapted to apply to other practitioners.

1975—Missouri revised statutes (1975) authorized a nurse to make an assessment of persons who are ill and to render a nursing diagnosis. The 1975 act not only described a much broader spectrum of nursing functions, but it also qualified this description with the phrase, “including, but not limited to.”

1980—The ANA published a model nurse practice act for state legislators to provide for consistency in individual state nurse practice acts.

1985—New York revised its definition of nursing by providing that a registered professional nurse who has the appropriate training and experience may provide primary healthcare services as defined under the statutory authority of the public health law and as approved by the hospital’s governing authority. The term primary healthcare services means taking histories and performing physical examinations, selecting clinical laboratory tests and diagnostic radiology procedures, and choosing regimens of treatment. These provisions do not alter a physician’s responsibility for patient care.

1989—New York allowed NPs to diagnose, treat, and write prescriptions within their area of specialty with minimum physician supervision.

1990—The ANA again amended its model definition for nursing practice to include the advanced NP as well as the registered nurse (RN).

2014—Doctor of Nursing Programs continue to expand.

A nurse who exceeds his or her scope of practice as defined by state nurse practice acts can be found to have violated licensure provisions or to have performed tasks that are reserved by statute for another healthcare professional. Because of increasingly complex nursing and medical procedures, it is sometimes difficult to distinguish the tasks that are clearly reserved for the physician from those that may be performed by the professional nurse. Nurses, however, generally have not encountered lawsuits for exceeding their scope of practice unless negligent conduct is an issue.

Nursing Diagnosis

Various states recognize that nurses can render a nursing diagnosis. This was the case in Cignetti v. Camel,3 where the defendant physicians ignored a nurse’s assessment of a patient’s diagnosis, which contributed to a delay in treatment and injury to the patient. The nurse testified that she told the physician that the patient’s signs and symptoms were not those associated with indigestion. The defendant physician objected to this testimony, indicating that such a statement constituted a medical diagnosis by a nurse. The trial court permitted the testimony to be entered into evidence. Section 335.01(8) of the Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis. On appeal, the Missouri Court of Appeals affirmed the lower court’s ruling, holding that evidence of negligence presented by a hospital employee, for which an obstetrician was not responsible, was admissible to show the events that occurred during the patient’s hospital stay.


Each state has its own nurse practice act that defines the practice of nursing. Although most states have similar definitions of nursing, differences generally revolve around the scope of practice permitted. The scope of practice of a licensed practical nurse (LPN) is generally limited to routine patient care under the direction of an RN or a physician.

An RN is one who has passed a state registration examination and has been licensed to practice nursing. The scope of practice of a registered professional nurse includes, for example, patient assessment, patient teaching, health counseling, executing medical regimens, and operating medical equipment as prescribed by a physician, dentist, or other licensed healthcare provider.

The common organizational pattern of nurse licensing authority in each state is to establish a separate board, organized and operated within the guidelines of specific legislation, to license all professional and practical nurses. Each board is in turn responsible for the determination of eligibility for initial licensing and relicensing; for the enforcement of licensing statutes, including suspension, revocation, and restoration of licenses; and for the approval and supervision of training institutions. A licensing board has the authority to suspend a license; however, it must do so within existing rules and regulations.

Requirements for Licensure

Formal professional training is necessary for nurse licensure in all states. The course requirements vary, but all courses must be completed at board-approved schools or institutions. Each state requires that an applicant pass a written examination, which is generally administered twice annually. A licensing board may draft examinations, or a professional examination service or national examining board may prepare them. Some states waive their written examination for applicants who present a certificate from a national nursing examination board. Graduate nurses are generally able to practice nursing under supervision while waiting for the results of their examination. The four basic methods by which boards license out-of-state nurses are (1) reciprocity, (2) endorsement, (3) waiver, and (4) examination.


This is a formal or informal agreement between states whereby a nurse licensing board in one state recognizes licensees of another state if the board of that state extends reciprocal recognition to licensees from the first state. To have reciprocity, the initial licensing requirements of the two states must be essentially equivalent.


Although some nurse licensing boards use the term endorsement interchangeably with reciprocity, the two words have different meanings. In licensing by endorsement, boards determine whether out-of-state nurses’ qualifications are equivalent to their own state requirements at the time of initial licensure. Many states make it a condition for endorsement that the qualifying examination taken in another state be comparable to their own. As with reciprocity, endorsement becomes much easier when uniform qualification standards are applied by the different states.


Some states license nurses by waiver and examination. When applicants do not meet all the requirements for licensure but have equivalent qualifications, the specific prerequisites of education, experience, or examination may be waived.


Some states will not recognize out-of-state licensed nurses and make it mandatory that all applicants pass a licensing examination. Most states grant temporary licenses for nurses, which may be issued pending a decision by a licensing board on permanent licensure or may be issued to out-of-state nurses who intend to be in a jurisdiction for a limited, specified time.

Graduates of schools in other countries are required to meet the same qualifications as nurses trained in the United States. Many state boards have established special training, citizenship, and experience requirements for students educated abroad; others insist on additional training in the United States. Nurses who complete their studies in a foreign country are required to pass an English proficiency examination and/or a licensing examination administered in English. A few states have reciprocity or endorsement agreements with some foreign countries.

Suspension and Revocation of License

Nurse licensing boards have the authority to suspend or revoke the license of a nurse who is found to have violated specified norms of conduct. Such violations may include procurement of a license by fraud; unprofessional, dishonorable, immoral, or illegal conduct; performance of specific actions prohibited by statute; and malpractice.

Suspension and revocation procedures are most commonly contained in the licensing act; in some jurisdictions, however, the procedure is left to the discretion of the board or is contained in the general administrative procedure acts. For the most part, suspension and revocation proceedings are administrative, rather than judicial, and do not carry criminal sanctions.

Practicing Without a License

Healthcare organizations are required to verify that each nurse’s license is current. The mere fact that an unlicensed practitioner is hired would not generally in and of itself impose additional liability unless a patient suffered harm as a result of the unlicensed nurse’s negligence. However, a person posing as a nurse could face criminal charges.


The next several pages describe a variety of nursing careers and case law examples of the risks some have encountered. Specific attention is given to registered nurses, traveling nurses, nurse managers, licensed practical nurses, certified nursing assistants, float nurses, agency nurses, special duty nurses, student nurses, and advanced practice nurses.

Registered Nurses

A registered nurse (RN) is a nurse who has graduated from an accredited nursing program and has passed a national licensing exam, known as the NCLEX (National Council Licensure Examination)-RN. NCLEX examinations are developed and owned by the National Council of State Boards of Nursing, Inc. (NCSBN), which administers these examinations on behalf of its member boards. NCSBN is a not-for-profit organization whose membership comprises the boards of nursing in the 50 states, including the District of Columbia, and four U.S. territories. There are also nine associate members.

Nurses wishing to practice in a particular state should be sure to contact the state’s nurse licensure body for information for specific registration and nurse licensing requirements.

Traveling Nurse

A traveling nurse is one who travels to work in temporary nursing positions in different cities and states. There are a variety of traveling professionals, such as physical therapists and physicians. The trav

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