Nurses have a significant duty to deliver proper medical care to their patients. This responsibility is not implied by the profession but is an integral part of official documentation to which nurses must adhere (Watson, 2014). With the development of the industry, healthcare delivery moved away from quantity-based results toward the quality of care (Watson, 2014). As a result, many efforts were made to standardize the process of care provision. Currently, the healthcare field follows an essential concept of compliance, which determines the issues in care delivery and shows how nurses have to act in their practice.
Compliance in Nursing
Compliance is a term that is used to describe nurses’ need to follow the standards of care set by federal and state health organizations. Regulations were created by the United States’ government to describe the scope of practice for all medical professionals (Buppert, 2018). Moreover, these guidelines define which procedures and activities are the best for patients, and what actions nurses and other medical workers have to take or must avoid. Notably, one of the goals of compliance is to prevent abuse and fraud by healthcare providers. In my practice, compliance means clarity – a full understanding of responsibilities as well as limits placed on the job of an Advanced-Practice Registered Nurse (APRN).
Regulatory and Coding Compliance
Coding compliance applies specifically to the processes of medical billing – an integral part of most healthcare organizations in the United States. The policies describing coding compliance refer to specialists’ guidelines for reporting procedures performed for the patient and the related payments requested from them (Jordan, Quraishi, & Liao, 2013). Coding documentation differs from one state to another, and even organizations can have their own unique rules. However, coding has to be reviewed by each facility annually, and the standards must integrate every document that has vital patient information. Another part of regulatory compliance is patient confidentiality – nurses need to preserve patients’ private information and protect it from fraudulent use (Buppert, 2018). For this purpose, a separate set of compliance policies exists.
Coding Compliance Issues: Comparison
As mentioned before, each state in the US has its own set of compliance policies that adds to the federal regulations. Most of the differences are concerned with nurses’ autonomy and scope of practice with or without supervision. For example, in the state of New Jersey, Nurse Practitioners (NPs) are recognized as primary care providers (Scope of Practice Policy, 2019). Similar to physicians, nurses are allowed to provide primary care, including geriatric, pediatric, and obstetrical/gynecological care (Scope of Practice Policy, 2019). In this comparison, the compliance regulations of the country and state place similar responsibilities on nurses and physicians.
Nevertheless, NPs do not possess full autonomy if they practice in NJ. Nurses have to collaborate with a physician when prescribing medication – the prescriptive authority is given to the supervisor (Scope of Practice Policy, 2019). Only specially licensed NPs can work with controlled substances, and they have to consult the supervising physician before completing the procedure (Scope of Practice Policy, 2019). Some exceptions apply as described by the NJ State Board of Medical Examiners, but, overall, NPs’ coding compliance requires a level of other specialist’s participation. In contrast, state regulations leave the decisions regarding nurses’ autonomy to the states, nor requiring physician supervision for licensed APRNs.
Failure to adhere to the standard of care does not always mean that the clinician responsible for this will be subject to legal action. In fact, only a small number of all medical workers get sued for malpractice, while the margin of error in patient treatment may be rather high (Miller, 2013). All procedures completed by nurses are guided by the principles of benevolence and nonmaleficence. They ensure that healthcare providers strive to improve patients’ health and do not do any harm to them (Westrick & Jacob, 2016). The legal implications of noncompliance do not always align with nurses’ lack of commitment to these founding ideas. Nonetheless, most laws are built on these principles – negligence arising as the main source of legal action.
The main legal implication of nursing negligence is a lawsuit. Such lawsuits can involve the nurse in question as well as supervising physicians, other nursing staff, and the organization where the procedures were performed (Stelmach, 2015). In states where NPs do not have full autonomy, the responsibility of a supervising physician may be especially significant in a lawsuit. Then, if a nurse loses the lawsuit of malpractice, the Board of Nursing may investigate the case further to determine the level of negligence and take action. In this scenario, the nurse may encounter additional circumstances if the Board finds signs of gross negligence and malicious intent.
Malpractice: Key Elements
The central concept that has to be considered in legal implications is malpractice. According to Buppert (2018), malpractice is a “failure of a professional to exercise that degree of skill and learning commonly applied by the average prudent, reputable member of the profession” (p. 272). There are four key elements that a plaintiff has to prove to support the malpractice case. The first one is the establishment of an NP’s duty to the patient. The basis of responsibility is the relationship between the patient and the provider. Apart from obvious cases, such as a hospital or office visit, telephone conversations and casual discussions with the patient or their representatives also designate a relationship (Buppert, 2018). It should be noted that a duty can be established in any setting – the patient has to believe that the relationship was present.
The second element is the nurses’ conduct falling below the standard of care. NPs’ reasonable care is dictated by the qualification, state and federal regulations, as well as the rules created by the healthcare organization. For instance, if nurses are working as primary care specialists, their duties will be similar to those of a physician. Other nurses play a significant role in establishing whether the defendant acted reasonably and according to standards since each patient case is unique and does not always conform to guidelines (Stelmach, 2015). Some standards of care were listed in the National Guideline Clearinghouse – they provided a solid basis for reasonable, evidence-based practice (Agency for Healthcare Research and Quality, 2016).
The nurse’s breach of standards of care has to have an effect on the patient to be considered as malpractice. Here, the causation of events is vital to the outcome. Nurse’s actions have to have a direct impact on the patient’s wellbeing. Buppert (2018) provides an example where the NP prescribes the patient a drug to which the patient is allergic. However, before taking the drug, the patient gets stung by a bee and falls on the steps of the clinic. The final injuries of the patient are not connected to the nurse’s incorrect prescription, thus, excluding the possibility of causation.
Finally, the patient’s injury constitutes malpractice, while the lack of an adverse outcome does not. Even if the NP makes an incorrect decision, the patient’s health is the primary determinant on which the case is built. If the patient suffers from the provider’s failure to adhere to the standard of care, a malpractice case has a foundation. Referring to the previous example, the NP who prescribes the drug to which the patient may be allergic does not act reasonably (Buppert, 2018). Nonetheless, if this patient takes this medicine and does not have an allergic reaction, malpractice does not happen.
Malpractice Policy Options
There are two main types of malpractice policies – occurrence and claims-made. The first option, occurrence policies, covers events that occur during a specified period, depending on the time noted by the policy (Buppert, 2018). These policies are expensive because they can cover a long period and do not require any action to be taken between an event of possible negligence happening and a claim being filled (Buppert, 2018). However, they are also the broadest in terms of their protection of the nurse. This makes them risky for insurance companies and costly for policyholders.
The second option is claims-made policies that have more conditions for coverage. First of all, they cover events that have occurred and were confirmed. Moreover, the holder of the policy has to report the incident of malpractice in a specified period following it (Buppert, 2018). Therefore, the NP gains a responsibility to timely report instances of misconduct regardless of whether they appeared in court. The failure to do so removes the coverage that would be provided by an occurrence policy. In some organizations, tail coverage is available to providers – it covers the claims that were reported after the claims-made policy was canceled or expired. Notably, this policy option is less risky for insurers, and it offers lower premiums and more flexible systems.
Compliance is a vital part of nurses’ practice as it supports the quality of care and provides nurses with reasonable limitations to the scope of their abilities. While nurses have an inherent duty to care for patients, they cannot always reach positive results or act perfectly. For this reason, the theory of negligence establishes clear boundaries for what can be considered malpractice – duty, performance below the standard of care, causation, and injury. NPs have several policy options to protect themselves from malpractice claims. However, regulatory and coding compliance with state and federal guidelines remains the best way of delivering the best possible care.
Agency for Healthcare Research and Quality (2016). National Guideline Clearinghouse.
Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Sudbury, MA: Bartlett & Jones Learning.
Jordan, L. M., Quraishi, J. A., & Liao, J. (2013). The national practitioner data bank and CRNA anesthesia-related malpractice payments. American Association of Nurse Anesthetists Journal, 81(3), 178-182.
Miller, K. P. (2013). The national practitioner data bank: An annual update. The Journal for Nurse Practitioners, 9(9), 576-580.
Scope of Practice Policy. (2019). New Jersey scope of practice policy: State profile.
Stelmach, E. I. (2015). Dismissal of the noncompliant patient: Is this what we have come to? The Journal for Nurse Practitioners, 11(7), 723-725.
Watson, E. (2014). Nursing malpractice: Costs, trends and issues. Journal of Legal Nurse Consulting, 25(1), 26-31.
Westrick, S. J., & Jacob, N. (2016). Disclosure of errors and apology: Law and ethics. The Journal for Nurse Practitioners, 12(2), 120-126.