5.5 Protecting Your Nursing License
You have worked hard to obtain a nursing license and it will be your livelihood. See Figure 5.8[1] for an illustration of a nursing license. Protecting your nursing license is vital.
Actions to Protect Your License
There are several actions that nurses can take to protect their nursing license, avoid liability, and promote patient safety. See Table 5.5 for a summary of recommendations.
Table 5.5 Risk Management Recommendations to Protect Your Nursing License
| Legal Issues | Recommendations to Protect Your License |
|---|---|
| Practicing outside one’s scope of practice |
|
| Documentation |
|
| Medication errors |
|
| Substance abuse and drug diversion |
|
| Acts that may result in potential or actual client harm |
|
| Safe-guarding client possessions & valuables |
|
| Adherence to mandatory reporting responsibilities |
|
Culture of Safety
It can be frightening to think about entering the nursing profession after becoming aware of potential legal actions and risks to your nursing license, especially when realizing even an unintentional error could result in disciplinary or legal action. When seeking employment, it is helpful for nurses to ask questions during the interview process regarding organizational commitment to a culture of safety to reduce errors and enhance patient safety.
Many health care agencies have adopted a culture of safety that embraces error reporting by employees with the goal of identifying root causes of problems so they may be addressed to improve patient safety. According to The Joint Commission, components of a culture of safety include the following:[10]
- Just Culture: A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless behaviors.
- Reporting Culture: People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” when a medication error occurs or a client falls according to agency policy. Reporting errors also assists the agency in performing risk management actions to reduce potential liability.
- Learning Culture: People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.
Just Culture
The American Nurses Association (ANA) officially endorses the Just Culture model. See Figure 5.9[11] for an illustration of Just Culture. In 2019 the ANA published a position statement on Just Culture. They stated that while our traditional health care culture held individuals accountable for all errors and accidents that happened to patients under their care, the Just Culture model recognizes that individual practitioners should not be held accountable for system failings over which they have no control. The Just Culture model also recognizes that many errors represent predictable interactions between human operators and the systems in which they work. However, the Just Culture model does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated).[12]
The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior:[13]
- Simple human error: A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[14]
- At-risk behavior: An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[15]
- Reckless behavior: Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[16]
These categories of errors result in different consequences to the employee based on the Just Culture model:
- If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[17] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
- Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[18]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
- If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[19] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.
When seeking employment, it is helpful for nurses to determine how an agency implements a culture of safety because of its potential impact on one’s professional liability and licensure.
- “aid9688616-v4-728px-Get-a-California-Endorsement-for-Your-Nursing-License-Step-11.jpg” by unknown is licensed under CC BY-NC-SA 3.0 ↵
- Nurses Service Organization and CAN Financial. (2020, June). Nurse spotlight: Defending your license. https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/claim-reports/cna_cls_nurse20_sl_061120p3_cf_prod_asize_online_sec.pdf ↵
- Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization and CAN Financial. (2020, June). Nurse spotlight: Defending your license. https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/claim-reports/cna_cls_nurse20_sl_061120p3_cf_prod_asize_online_sec.pdf ↵
- Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
- Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
- Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
- Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- The Joint Commission. (2017, March 1). The essential role of leadership in developing a safety culture. Sentinel event alert, Issue 57. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_57_safety_culture_leadership_0317pdf.pdf ↵
- "Just Culture Infographic.png" by Valeria Palarski 2020. Used with permission. ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
Culture that embraces error reporting by employees with the goal of identifying root causes of problems so they may be addressed to improve patient safety.