Laws and Rules Governing Nursing Practice In Florida
About the Author
Angeline Bushy, PhD, RN, FAAN is the Bert Fish Eminent Scholar Endowed Chair, University of Central Florida, College of Nursing. Professor Bushy is recognized for advancing nursing education and community healthcare. She has published extensively, including textbooks, and presented various aspects of rural healthcare delivery at numerous national and international conferences. She has practiced in a variety of rural health care settings including community, acute care and educational settings, and served in the U.S. Army Nurse Corps (LTC, Ret.) for more than 20 years.
Purpose and Goals
The purpose of this continuing education course is to provide basic knowledge of the laws and rules governing the practice of nursing in Florida in order to increase compliance and improve patient care. Florida nurses are legally obligated to be aware of standards that govern professional accountability. Information contained in this course is not intended for use in lieu of lawful guidelines, but rather as a learning tool that increases the understanding of some regulations as these apply to nurses who are licensed within the state of Florida. The goal is to provide information regarding current laws and rules related to the practice of nursing in Florida. The content includes Basic law principles, Florida Statutes of Chapters 456 and 464 (Nurse Practice Act) and Rules of Title 64B9 of the Florida Administrative Code. This course exceeds the two-hour CE requirement written in the administrative law by the Florida Board of Nursing.
Upon completion of this material, the dedicated learner will be able to:
- Describe the role of the Florida Board of Nursing (FL-BON).
- Recognize relevant legal terms for professional nursing practice.
- Describe the legislative purpose for the Nurse Practice Act.
- Identify specific laws and rules related to the practice of nursing and nursing assisting.
- Highlight the various levels of nursing practice in the state and the scope of practice for each.
- Understand general requirements of continuing licensure in Florida.
- Differentiate between ethical and legal practice issues.
- Discuss the Impaired Nursing Project (IPN) and its role in violations and discipline actions.
The practice of nursing requires specialized knowledge, skill and independent decision-making. Nursing careers take widely divergent paths – practice varies by setting, by type of client, by different diseases, therapeutic approach and level of rehabilitation. Nurses are mobile, sophisticated and work in a society that is changing and asymmetrical for consumers. The result is that the risk of harm is inherent in the provision of nursing care. Because nursing care has inherent risk of harm to the public if practiced by professionals who lack preparation or competence, state governments protect its citizens from harm. That protection is in the form of reasonable laws to regulate nursing. (National Council of State Boards of Nursing (NCSBN), https://www.ncsbn.org).
As in many industries, laws and regulations significantly impact functioning of the healthcare industry. All licensed health professionals must function within established standards and guidelines as mandated by local, state, and federal laws. Licensed nurses also fall under these guidelines. Each state defines the scope and standards of nursing with its Nurse Practice Act (NPA). All states have enacted NPAs. Some laws relating to scope of practice and malpractice regulate the manner in which the industry and the nursing profession operate. Others affect the organization and the environment itself. Therefore, it is increasingly important that nurses who work in a specific state understand its complex and dynamic legal practice parameters.
The ultimate purpose of the NPA is protection of the public! Healthcare professionals are required to make decisions or complete tasks that can result in legal action initiated by coworkers or patients. Most nurses have the dedication, motivation, education and training to accomplish their responsibilities accurately and professionally. However, there are instances, regardless of strict adherence to accepted standards of practice that may occur which could result in litigation. To avoid such events, the nurse must be informed about current laws, statutes, regulations and standards that apply in day-to-day practice; along with available options should one’s professional conduct be questioned in a court of law.
Introduction to Law
Legal systems, and the conditions under which nurses work vary worldwide. This continuing education course focuses on the U.S. legal system. In most basic nursing education programs, students learn about three sources of law in the United States; statutory law, administrative law, and common law; and, discussions about liability, negligence, and the Good Samaritan Act. The next section of this course provides more details on these concepts.
Sources of Law
There are three basic sources of law in the United States: statutory, administrative, and common law.
Statutory Law includes those principles and rules enacted by legislative bodies. These "statutes" become laws after they are first approved by the Senate and House of Representatives and then signed by the governor or the President. The enacted laws rest in hierarchical order. In other words, the US Constitution, federal law, and federal treaties take precedence over the constitutions and laws of states and local jurisdictions. Often cases involving statutory laws are heard in courts where judgments are made as an interpretation of a statute as it relates to a specific case pending. In Florida the law that regulates the practice of nursing is Title XXXII Chapter 456 Regulation of Professions and Occupations Chapter 464 Nursing, referred to as the Florida Nurse Practice Act (NPA).
Administrative Law takes the form of rules and regulations enacted by agencies created by legislatures. Examples include: the Federal Trade Commission (FTC), and the Food and Drug Administration (FDA). In Florida, the rules and regulations for the NPA is called the Florida Administrative Code (FAC) rule 64B9.
Common Law is law originating from individual case decisions in various federal, state, and local courts. When a common law principle has been declared in a state court decision, the principle must be followed for similar cases in the future by other courts within the state where the decision was rendered.
A decision that yields a new legal principle establishes a precedent. However, a precedent set in one state does NOT set a precedent within another state. Also, prior decisions can be overruled if there is a change in social attitudes, public needs or contemporary political thinking. Most laws involving malpractice cases come from common law, therefore malpractice suits that have already been decided serve as a guide for future decisions.
Tort Law: A tort refers to a civil wrong committed against a person or property (real or personal) and is punishable by damages (monetary compensation) rather than imprisonment. There are three categories of torts: Intentional, Negligent, and Strict Liability torts where liability is assessed irrespective of fault.
Intentional Torts occur when the plaintiff must prove that the willful act committed by the tort-feasor (one who commits a tort) was "intentional", meaning it was known with a high degree of certainty that harm to another would result. Potential tortuous conduct includes assault, battery, false imprisonment, invasion of privacy, disclosure of information, defamation of character and infliction of mental distress. Several of these terms will be discussed in detail in the next section.
Assault: The act of creating apprehension of an immediate harmful, offensive, or unauthorized contact to a person.
Battery: The harmful, offensive, or unauthorized touching of another person. A patient may be the receiver of the battery and not be aware that it has occurred. For example, the case of an unconscious person who undergoes surgery without informed consent, either implied or expressed. Nurses should keep in mind, that patients are 'touched' by many individuals during a hospitalization. Procedures ranging from the initial assessment, to bathing, taking vital signs, administering medications, to surgery all involve TOUCHING. All of these procedures and activities have inherent risks. Fortunately, not every patient is seeking an opportunity to sue; nonetheless incidents can occur that result in legal action.
In the eyes of the law, the fact that the patient benefited from your unconsented touching is not as important as whether or not you had permission to touch him or her in the first place. An adult patient who is alert and oriented has the right to refuse any aspect of treatment.
Disclosure of Information: This legal term is similar to invasion of privacy. It occurs when a patient's problems, condition or diagnosis is inappropriately discussed with any third party (including “non” authorized family members). Information given to nurses by patients often is personal and highly sensitive. The Patient's Bill of Rights states that the patient has the right to expect confidentiality in the healthcare relationship. Be careful of what you say and to whom you say it. The nurse is still responsible for reporting certain information as imposed by state law. However, if you report "legally reportable" information and later learn that your finding was erroneous, you may be held liable for the disclosure, BUT you can be protected if your error was in good faith.
Negligent Torts: Although the terms "negligence" and "malpractice" are often used interchangeably, you should be aware of the difference.
Negligence: Doing something or failing to do something that a "reasonable and prudent" person, facing the same circumstances, would not do.
Malpractice: This is similar to negligence but is more specific in that the act is committed or omitted by a professional person who has deviated from a standard of care. There are four elements of malpractice that must be proven in order for a plaintiff to recover damages.
Duty of Due Care: The level of responsibility a person is expected to practice in a given situation. This is easiest to prove especially if the nurse practices in a hospital setting. The only proof needed is that a relationship existed between the nurse and patient at the time of the alleged injury. This relationship exists merely by having the patient ON THE NURSE’S ASSIGNED UNIT, even if the patient is not assigned to the nurse’s care. For example, a duty of due care may exist when walking past the room of a patient NOT assigned directly to the nurse, if patient calls out for assistance.
Breach of Duty: This is defined as the failure to adhere to the standard of care set by the nursing profession thus departing from the specific duty owed to the patient. Evidence of breach of duty presented to a jury includes: testimony (i.e. expert witnesses), circumstantial evidence, or res ipsa loquitor (“the thing speaks for itself”; see Appendix A: Legal Terms).
Reasonably Prudent Person Doctrine: This legal "test" relies on the doctrine that asks, "Did the defendant (nurse) act reasonably under the circumstances?" Should a nurse be accused of breach of duty in Florida, the Standard of Care written in the NPA would be used to determine whether the action was breached by unprofessional conduct. FAC Rule 64B9-8.005 states:
Unprofessional conduct shall include:
- Inaccurate recording;
- Misappropriating drugs, supplies or equipment;
- Leaving a nursing assignment without advising licensed nursing personnel;
- Stealing from a patient;
- Violating the integrity of a medication administration system or an information technology system;
- Falsifying or altering of patient records or nursing progress records, employment applications or time records;
- Violating the confidentiality of information or knowledge concerning a patient;
- Discriminating on the basis of race, creed, religion, sex, age or national origin, in the rendering of nursing services as it relates to human rights and dignity of the individuals;
- Engaging in fraud, misrepresentation, or deceit in taking the licensing examination;
- Impersonating another licensed practitioner, or permitting another person to use his certificate for the purpose of practicing nursing;
- Providing false or incorrect information to the employer regarding the status of the license;
- Practicing beyond the scope of the licensee’s license, educational preparation or nursing experience;
- Using force against a patient, striking a patient, or throwing objects at a patient;
- Using abusive, threatening or foul language in front of a patient or directing such language toward a patient.
- Accepting a gift from a patient the value of which exceeds the employer’s policy regarding gifts.
- Knowingly obtaining or using or attempting to obtain or use a patient’s property with the intent to temporarily or permanently deprive the patient of the use, benefit or possession of the funds, assets or property, or to benefit someone other than the patient.
Note that items 15 and 16 were added in the 2017 revision.
A hearing by the Board of Nursing will determine sanctions.
Injury (Damages): This legal element includes not only physical harm but also mental anguish and other invasions of plaintiff's (patient) rights. The nurse may be negligent but not liable if no injury results to the patient. Damages: A plaintiff must show some measurable harm occurred to win the case.
Proximate Cause (Causation): This involves the concept of "foreseeability". A logical link must exist between the nurse's act and the injury suffered. It also relies on the "but for" test: "But for the 'act' the injury would not have occurred. It must be clearly understood that the mere departure from a standard procedure alone is not enough evidence to allow a patient to recover damages. Therefore, if there exists a logical link, but NO proximate cause, there is NO liability.
After hearing the facts and testimony of a case, the jury will be asked to examine these questions:
- a) Did the nurse fail to adhere to the standard of care practiced by the nursing profession in this situation. b) If yes, was it foreseeable that harm would result?
- Was the negligence the immediate cause of the injury?
The sole fact that injury is suffered without proof that the nurse deviated from the practice of competent members of the profession is NOT enough for imposing liability upon the nurse.
Good Samaritan laws: These laws offer legal protection to individuals who offer reasonable assistance to those who are, or who they believe to be, injured, ill, in peril, or otherwise incapacitated. Essentially, the intent of this legislation is to reduce a bystander’s reluctance to assist another person, for fear of being sued or prosecuted for unintentional injury or wrongful death. The purpose is to encourage providing assistance to a stranger without fear of legal repercussions should he or she make a treatment error. Conversely, the duty to rescue law requires an individual to offer assistance and holds someone liable who fails to do so.
A state’s Board of Nursing is the authoritative body responsible for ensuring that nurses who practice in that state are competent, safe, skilled and knowledgeable about the standards set forth in that state’s scope of practice for nurses. Each state’s NPA is enacted by the legislature. The NPA is insufficient to provide the necessary guidance for the nursing profession. Therefore, each NPA established a Board of Nursing (BON) that has the authority to develop administrative rules or regulations to clarify or make the law more specific.
All states NPAs include:
- Authority, power and composition of a BON
- Education program standards
- Standards and scope of nursing practice
- Types of titles and licenses
- Requirements for licensure
- Grounds for disciplinary action, other violations, and possible remedies (NCSBN, 2014)
With the legal foundation laid and the framework of laws, standards, and practice issues in place, lets examine how Florida Laws and Rules apply to nursing to protect our patients and our selves
Florida Statutes and Administrative Law that Regulate Nursing
Florida Law Title XXXII Regulations of Professions and Occupations Chapters 456 and 464
The Florida statues are organized into 58 titles, each with a number of chapters. Title XXXII Regulation of Professions and Occupations, chapter 456 describes general provisions related to health provision to health occupations and professions. Chapter 464 of this statute is specifically related to nursing and certified nursing assistants. This is referred to the Nurse Practice Act (NPA). All these statutes are written by the state legislature.
The NPA of Florida (Chapter 464.004,464.006) gives the authority to the Florida Board of Nursing (FBN) to administer and enforce the provisions of law. The purpose of this act is to ensure that every nurse practicing in Florida meets minimum requirements for safe practice. It is the legislative intent that nurses who fall below minimum competency or who otherwise present a danger to the public shall be prohibited from practicing in this state. (464.002). This regulation is to ensure that every nurse practicing in Florida meets minimum competency. The FBN has authority over Registered Nurses, Advanced Practice Nurses, Licensed Practical Nurses, and Certified Nursing Assistants.
The FBN differs from the Florida Nurses Association (FNA) in that the FBN derives its authority from state law and is part of the state government, while the association is a professional, voluntary membership organization for professional nurses living and working in the state. The FNA has NO legal authority, but provides legislative, educational, practice consultation, and collective-bargaining services for its members. Its mission is: “To serve and support all registered nurses through professional development, advocacy and the promotion of excellence in every area of professional nursing practice."
Florida Administrative Code
Department of Health Division 64B9 Board of Nursing
The general rules that regulate professional practice in Florida are: determine eligibility to sit for the examination to practice; issue and renew licenses; determine disciplinary action for nurses; define minimum curricula and standards for educational programs of schools of nursing; grant approval for prelicensure nursing programs; continuing nursing education requirements; establish a rule for impaired nurses; identify sexual misconduct in the practice of nursing; and issue and certify authority to practice nursing for selected advanced practice nurses. (FAC rule 64B9) These rules are written and approved by the Florida Board of Nursing.
Division 64B9 of the Florida Administrative Code gives specifics such as definitions, levels of nursing practice, and disciplinary rules from the Florida NPA. The FAC contains rules and regulations for all aspects of nursing practice in the state of Florida. (Accessed November 1, 2018, http://www.floridasnursing.gov
|Florida Statutes and Florida Administrative Code|
|Title XXXII, Florida Statutes||Chapter 456
Health Professions and Occupations General Provisions
Part I: The Florida Nurse Practice Act
Part II: Certified Nursing Assistants
|Florida Administrative Code||Chapter 64B9
Rules of the Florida Board Nursing
Competency Standards for RNs
Registered nurses provide nursing care within the scope of practice as defined by the statute. "The practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm, and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. And (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection." (FL, NPA, 464.003 Definitions). These regulations guide the nurse to maintain knowledge of the duties, responsibilities, and accountabilities for safe nursing practice.
Registered nurses must be competent and accountable in all areas of practice, including consistent performance of all aspects of nursing care and appropriate recognition, referral or consultation, and intervention when complications arise.
RNs may provide nursing care beyond basic nursing education preparation for an RN; provided they obtain additional education, demonstrate appropriate knowledge, skills, and abilities, and document their action. Such nursing care cannot involve a function or procedure that is prohibited by any law or rules.
For administration of medications and treatments, generally an RN must clarify and implement any prescribed regimen, direction, or treatment for a patient in a timely manner unless the RN believes the prescribed treatment is inaccurate, not properly authorized, not current or valid, harmful, or potentially harmful to a patient or contraindicated by other documented information. When an RN decides not to follow a direction or administer a prescribed medication, she or he must notify the prescribing practitioner, document that fact, and state the reason for not following the direction. No matter what the circumstances, however, the RN must take action to ensure the safety of the patient.
Registered nurses maintain the confidentiality of patient data, only communicating appropriate patient information to other members of the healthcare team for healthcare purposes. The RN shall access patient information only for purposes of patient care, or for otherwise fulfilling the nurse's assigned job responsibilities and shall not disseminate patient information for purposes other than patient care or for otherwise fulfilling the nurses' assigned job responsibilities through social media, texting, emailing, or any other form of communication. The RN does not disclose identifiable patient healthcare information unless the patient gives consent through a properly executed document. Only in limited circumstances, in accordance with authorized law, rule, or legal authority, may an RN give out identifiable patient information. This was clarified by a federal act in 1996 by the Health Insurance Portability and Accountability Act (HIPAA).
An RN uses acceptable standards of safe nursing care as a basis for any observation, advice, instruction, teaching, or evaluation and communicates information that is consistent with acceptable standards of safe nursing care.
The RN supervises and teaches the theory and performance of any of the nursing acts. When an RN gives direction to a LPN, the RN first assesses the condition of the patient who needs nursing care, including the type, complexity, and frequency of care. The RN also assesses the skill and ability of the LPN who is to perform the care and the availability and accessibility of resources needed to perform the procedure.
Adapted from Statute Chapter 464 .001-027
Competency Standards For Advanced Practice Registered Nurses (APRNs) (NPA section 464.012, F.S)
Most NPAs have a distinct licensure for APRNs (i.e., nurse practitioners, certified nurse anesthetists, nurse midwives). An advanced registered nurse practitioner shall perform those functions authorized in this section within the framework of an established protocol which must be maintained on site at the location or locations at which an advanced registered nurse practitioner practices. In the case of multiple supervising physicians in the same group, an advanced registered nurse practitioner must enter into a supervisory protocol with at least one physician within the physician group practice. An advanced registered nurse practitioner may:
- Prescribe, dispense, administer, or order any drug; however, an advanced registered nurse practitioner may prescribe or dispense a controlled substance as defined in s. 893.03 only if the advanced registered nurse practitioner has graduated from a program leading to a master’s or doctoral degree in a clinical nursing specialty area with training in specialized practitioner skills.
- Initiate appropriate therapies for certain conditions.
- Order diagnostic tests and physical and occupational therapy.
In addition to the general functions of an advanced or specialized nursing practice, an APRN practitioner may perform additional advanced-level nursing acts related to the specialty area (e.g. psychiatry, primary care, pediatrics, women’s health et al.)
- Manage selected medical problems
- Order physical and occupational therapy
- Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses.
- Monitor and manage patients with stable chronic diseases.
- Establish behavioral problems and diagnosis and make treatment recommendations.
Certified Registered Nurse Anesthetist (CRNA)
The certified registered nurse anesthetist may, to the extent authorized by established protocol approved by the medical staff of the facility in which the anesthetic service is performed, perform any or all of the following:
- Determine the health status of the patient as it relates to the risk factors and to the anesthetic management of the patient through the performance of the general functions.
- Based on history, physical assessment, and supplemental laboratory results, determine, with the consent of the responsible physician, the appropriate type of anesthesia within the framework of the protocol.
- Order under the protocol preanesthetic medication.
- Perform under the protocol procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, therapeutic, or diagnostic clinical procedures. These procedures include ordering and administering regional, spinal, and general anesthesia; inhalation agents and techniques; intravenous agents and techniques; and techniques of hypnosis.
- Order or perform monitoring procedures indicated as pertinent to the anesthetic health care management of the patient.
- Support life functions during anesthesia health care, including induction and intubation procedures, the use of appropriate mechanical supportive devices, and the management of fluid, electrolyte, and blood component balances.
- Recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medication, or other forms of therapy.
- Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care.
- Participate in management of the patient while in the postanesthesia recovery area, including ordering the administration of fluids and drugs.
- Place special peripheral and central venous and arterial lines for blood sampling and monitoring as appropriate.
Certified Nurse Midwife (CNM)
The certified nurse midwife may, to the extent authorized by an established protocol which has been approved by the medical staff of the health care facility in which the midwifery services are performed, or approved by the nurse midwife’s physician backup when the delivery is performed in a patient’s home, perform any or all of the following:
- Perform superficial minor surgical procedures.
- Manage the patient during labor and delivery to include amniotomy, episiotomy, and repair.
- Order, initiate, and perform appropriate anesthetic procedures.
- Perform postpartum examination.
- Order appropriate medications.
- Provide family-planning services and well-woman care.
- Manage the medical care of the normal obstetrical patient and the initial care of a newborn patient.
Competency Standards For LPNs
A licensed practical nurse (LPN) functions within the scope of practice of an LPN as set forth in the Florida Statute NPA 464.003 and the Florida codes (rules) rule #64B9 written by the Florida Board of Nursing.
Statute 464.003(17) states, “’Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm; the promotion of wellness, maintenance of health, and prevention of illness of others under the direct supervision of a registered nurse, a licensed physician, a licensed osteopathic physician, licensed podiatric physician, or a licensed dentist; and the teaching principles of health and wellness to the public and to students other than nursing students. A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing."
An LPN may provide nursing care beyond basic preparation for an LPN provided the LPN obtains appropriate education and demonstrates knowledge, skills, and abilities and maintains satisfactory documentation of meeting these requirements. An example of one area of practice is the administration of IV therapy. The Florida Board of Nursing has a rule that states when necessary that a licensed practical nurse, when qualified by training and education, and when approved by the institution where nurse is employed, may engage in limited administration of IV therapy both to serve the public and to allow the professional nurse (RN) to better perform those acts requiring professional nursing specialized knowledge, judgment and skill. The rule also enumerates those aspects of IV therapy outside the scope of LPN and sets educational and/or competency verification necessary to administer, under direction, limited forms of IV therapy. FAC 64B9-12.
An LPN reports to and consults with other nurses or other members of the healthcare team and make referrals as appropriate. An LPN maintains the confidentiality of patient information obtained in the course of nursing practice. The LPN communicates appropriate patient information with other members of the healthcare team for healthcare purposes only. An LPN does not disclose identifiable patient healthcare information unless the patient gives written consent by a properly executed release of information. The LPN must follow the same standards as the RN regarding confidentiality.
(Accessed November 1, 2018, http://www.floridasnursing.gov & https://floridasnursing.gov/resources/)
Supervision by Licensed Practical Nurses in Nursing Home Facilities (FAC 64B9-16.002)
This rule for LPNs has specific tasks that the LPN must take when supervising LPNs, CNAs and unlicensed assistive personnel (UAP). The LPN must first have at least six months employment of full-time clinical nursing experience in a hospital or nursing home. Other criteria are that the LPN must take a thirty-hour **post basic** education practical nurse supervisory course approved by the Board of Nursing or may qualify to supervise if the nurse has successfully completed a supervisory course on a post-graduate level and a provider credits the nurse for such course. Each component of the course content of certain F.A.C. paragraphs must be tested by and competency demonstrated to the provider; and that there is a Registered Nurse that supervises the LPN.
Tasks and activities delegated by the LPN to the CNA or UAP must be within the area of responsibility of the nurse delegating the task; and the task or activity must be within the knowledge, skills, and ability of the delegating LPN. In addition the task must be of routine and/or repetitive nature, and shall not require the CNA or UAP to exercise nursing knowledge, judgment or skill. The CNA or UAP must be able to perform the task with the degree of care and skill that would be expected of the nurse.
(Accessed November 1, 2018, http://www.floridasnursing.gov & https://floridasnursing.gov/resources/ www.flrules.org/gateway/ChapterHome.asp?Chapter=64B9-16 )
Delegation of Nursing Tasks to Unlicensed Assistive Personnel (UAP)
One of the legal issues that may need clarification to licensed nurses (both RNs and LPNs) is in the area of delegation to unlicensed persons to perform selected nursing tasks. This has been increasingly important in the care of patients outside hospitals and nursing homes. The Florida Board of Nursing has authorized criteria and standards for the licensed nurse to follow. Delegation of Nursing Tasks is promulgated in rules of the Florida Administrative Code (64B9 Chapter 14). "Delegation is the transference to a competent individual the authority to perform a selected task or activity in a selected situation by a nurse qualified by licensure and experience to perform the task or activity." (FAC 64B9-14.001 (5).
Rules for Delegation of Tasks
Delegation of tasks or activities are in FAC 64B9-14.002. The licensed nurse (RN or LPN) may delegate if all the conditions for delegation set forth in this chapter are met. Prior to delegating a nursing task to an unlicensed person, the nurse must determine if the task is within the scope of practice of the delegating nurse and that the nursing task is within the knowledge, skill, and ability of the nurse delegating. In addition the delegating nurse must identify if the nursing task is within the training, ability, and skill of the unlicensed person. Supervision by the licensed nurse must be adequate and available. Some of the factors that must be weighed before the nurse makes the decision to delegate a task are: (1) Is there are potential for patient harm; (2) complexity of the task; (3) predictability or unpredictability of outcome including reasonable potential for a rapid change in the medical status of the patient; (4) level of interaction required or communication available with the patient; and (5) resources both in equipment and personnel available in the patient setting.
The delegation must be within the normal assignment of the UAP; and the licensed nurse must validate or verify the education and training of the delegate. The delegation process shall include communication to the UAP which identifies the task or activity, the expected or desired outcome, the limits of authority, the time frame for the delegation, the nature of the supervision required, verification of delegate's understanding of the assignment, and verification of monitoring and supervision. The allocation of the task to the delegate, periodic inspection of the accomplishment of such task and total nursing care responsibility remains with the qualified nurse delegating the task and assuming responsibility for the supervision. Specific, accurate documentation is necessary for all delegation done.
Delegation of Tasks Prohibited
Certain tasks are prohibited by the NPA and are promulgated into the FAC rule 64B9-14.003 to be delegated. The nurse (RN or LPN) shall NOT delegate those: (1) activities not within the delegating nurse's scope of practice and (2) Nursing activities that include the use of the nursing process and require the special knowledge, nursing judgment or skills of the registered or practical nurse, including: the initial nursing assessment or any subsequent assessments; the determination of the nursing diagnosis or interpretations of nursing assessments; establishment of the nursing care goals and development of the plan of care; and evaluation of progress in relationship to the plan of care. Any task that the UAP has not demonstrated competence should also be prohibited. (FAC B4B9-14.003)
(Accessed November 1, 2018, www.flrules.org/gateway/ChapterHome.asp?Chapter=64B9-14 )
Patient Safety Standards
Promoting patient safety is a top priority in professional nursing practice.
A registered nurse and the licensed practical nurse shall maintain current knowledge of the duties, responsibilities, and accountabilities for safe nursing practice. At all times when a licensed nurse is providing direct nursing care to a patient, the licensed nurse shall display the applicable title or initials to identify the nurse's relevant licensure as a registered nurse or as a licensed practical nurse.
A registered nurse shall demonstrate competence and accountability in all areas of practice in which the nurse is engaged that includes, but is not limited to, the following:
Consistent performance of all aspects of nursing care
Appropriate recognition, referral or consultation, and intervention, when a complication arises.
The nurse obtains appropriate education that emanates from a recognized body of knowledge relative to the nursing care to be provided. Licensed nurses must implement measures to promote a safe environment for patients and maintain a professional boundary between themselves and patients. They must provide privacy during examination and care and treat patients with individual dignity, courtesy, and respect. Licensed nurses shall not engage in behavior that causes or may cause physical, verbal, mental, or emotional abuse to a patient or engage in behavior that a reasonable person would interpret as abuse.
The nurse-patient relationship is founded on mutual trust. The NPA (Chapter 464.017) states that the licensed nurse may not engage in behavior that constitutes an inappropriate personal relationship that is induced by the nurse or engage in sexual conduct with a patient, or engage in conduct that may be interpreted as sexual, seductive, or demeaning to a patient. Any sexual conduct is prohibited. These actions will be grounds for disciplinary action by the Florida Board of Nursing.
When licensed nurses function in administrative roles, they must make sure that procedures are in place and implemented to verify that every nurse working under their direction has a current valid license to practice nursing in the role to which the nurse is assigned. Only RNs may supervise or evaluate the nursing practice of RNs and LPNs; however, non-nursing supervisors may evaluate nurse employees in matters other than the practice of nursing.
Supervision by the registered nurse requires that the nurse be continuously available through some form of telecommunication with the nurse being supervised and at times make on-site visits to ensure that the one being supervised is practicing within the current standards of nursing practice. To make periodic evaluations the supervising nurse must make periodic on-site visits to prepare an evaluation of the nurse's performance. This is particularly important in home health care.
Applying Standards For the Nursing Process (RNs/APRNs)
Registered nurses and Advanced Practice Nurses give care to patients using the steps of the nursing process that are cyclical in nature so that the nurse's actions are directed by the patient's changing status throughout the process. In other words, a patient's changing status affects the action of nurses as they assess, analyze and report, plan, implement, and evaluate the patient's status. The nurse collaborates, as appropriate, with the patient, family, significant others, and other members of the healthcare team in applying the steps of the nursing process.
The following standards shall be used by RNs/APRNs, using critical thinking and clinical judgment, in applying the nursing process for each patient under the nurse's care.
Assessment involves the accurate and timely collection of both subjective and objective information about a patient's condition from the patient, family members, significant others, and members of the healthcare team. The RN/APRN may delegate the gathering of data, but must document and report it, as appropriate, to other members of the healthcare team.
In an accurate and timely way, nurses analyze data, identifying, organizing, and interpreting it. They then establish, accept, or modify the nursing diagnosis that is used as a basis for nursing interventions.
Nurses establish, maintain, or improve the nursing care plan, including desired patient outcomes and interventions. They communicate the plan to appropriate members of the healthcare team.
Nurses implement the current nursing care plan. They execute current valid orders or directions by a licensed practitioner, and give direct nursing care commensurate with their education, knowledge, skills, and abilities. They assist with care of the patient as necessary; collaborate with other healthcare team members, and delegate nursing tasks appropriately.
In an accurate and timely way, nurses evaluate, document, and report patient responses to nursing interventions to appropriate members of the healthcare team. They assess the patient's response to nursing interventions; and progress towards expected outcomes of the plan of care. Evaluation includes the "always important" step of documentation and communication of the patient's response to nursing interventions
Duties and Standards For the Nursing Process (LPNs)
Licensed practical nurses participate in the nursing process set in place in the Florida Administrative Code as rules of the FNB. They collaborate, as appropriate, with the patient, family, significant others, and members of the healthcare team. The standards for applying the nursing process follow.
The LPN contributes to the nursing assessment of a patient. In an accurate and timely manner, LPNs collect and document objective and subjective data related to the patient's health status and report the data to appropriate members of the team.
In an accurate and timely manner, LPNs contribute to the development, maintenance, or modification of the nursing component of the care plan and report the nursing component and all modifications of the plan to RN, other healthcare provider, and other members of the healthcare team.
LPNs implement the nursing care plan in an accurate and timely manner by: administering medications and treatments prescribed by an authorized person; giving direct basic nursing care; and assist in the care of the patient at the direction of an RN, physician, advanced nurse practitioner, and other legally licensed personnel. They work together with other nurses and members of the healthcare team, delegating appropriate nursing tasks such as administering selected topical medications.
LPNs contribute to the evaluation through documentation and reporting information to appropriate members of the healthcare team, and contribute to the revision of the nursing components of the plan of care on the basis of the evaluation.
Intervention Project for Nurses (IPN)
The IPN was established in 1983 through passage of legislation. IPN is one of Florida’s designated Impaired Practitioner Programs (IPP). IPN under contract with the Florida Department of Health (DOH) provides state-wide education, support and monitoring to nurses with impairing conditions such as substance use disorders, psychiatric and physical conditions. Nurses are most often referred to IPN by nursing employers due to potential safety to practice concerns. Florida statute 456.076 provides legislative authority for both IPN and PRN.
The mission of IPN is to ensure public health and safety by providing education, monitoring, and support to nurses in the State of Florida
The IPN objectives are:
- To protect, health, safety and welfare of the public, as risks to patients increase when a nurse providing care has an active impairing condition
- To offer consultation and educational programs to encourage earlier identification and action when fitness to practice concerns are present.
- To provide support, and monitoring to nurses appropriate for IPN while assisting each to maintain professional licensure.
- To supply a cost-effective avenue to help nurses as an alternative to the traditional disciplinary process.
- To retain nurses in the nursing profession.
(Accessed November 1, 2018 https://floridasnursing.gov/intervention-project-for-nurses & https://ipnfl.org/
enhanced Nurse Licensure Compact
“Florida is a member of the enhanced Nurse Licensure Compact (eNLC). The eNLC allows a registered nurse or licensed practical nurse licensed in a Compact state to practice across state lines in another Compact state without having to obtain a license in the other state.” The eNLC supersedes the prior compact, the Nurse Licensure Compact (NLC) that was implemented in 2000. Members of what is now referred to as the “prior compact”, of which Florida was one, were deemed to have withdrawn from the original NLC within six months of when the eNLC became effective. The use “enhanced” or “e” in eNLC is expected to go away over time, with the accepted parlance transitioning to NLC.
The eNLC requires nurses to adhere to the nursing practice laws and rules of the state in which he/she practices under his/her Compact license. If a nurse moves from one state to another and establishes residency, the nurse must apply for licensure in that state. For a list of states that have joined the compact, please see ncsbn.org
Florida began issuing multi-state licenses under the eNLC on January 19, 2018 for new applicants and those wanting to convert to the multi-state license. The multi-state license is a separate application with an associated fee; it not mandatory that a LPN or RN apply for the multi-state compact license. A “Single-State license” is issued by the Florida Department of Health to practice as a registered nurse (RN) or a licensed practical nurse (LPN) within the state of Florida. The single-state license does not include a multi-state licensure privilege to practice in any other Nurse Licensure Compact state.
To convert from a single-state license to the multi-state license, applicants must meet the following requirements.
- Have a current, clear, active license
- Graduated from a qualifying education program (or graduated from a foreign program verified by independent credentials review agency)
- Pass the NCLEX exam
- Have no active discipline on a license
- Submit to a federal criminal background check
- Have no felony conviction
- Not currently enrolled in an alternative to discipline program (i.e. IPN)
- Have a valid U. S. Social Security number
(Accessed November 1, 2018) https://floridasnursing.gov/enhanced-nurse-licensure-compact-faqs/
The Florida Board of Nursing licenses, monitors, disciplines, educates and, when appropriate, rehabilitates its licensees to assure their fitness and competence in providing health care services for the people of Florida. The sole legislative purpose in enacting the Nurse Practice Act is to ensure that every nurse practicing in Florida meets minimum requirements for safe practice. It is the legislative intent that nurses who fall below minimum competency or who otherwise present a danger to the public shall be prohibited from practicing in the State of Florida.
Specific sections of information contained in this course are derived from the Florida Nurse Practice Act (NPA) and Florida Administrative Code (FAC). It is recommended that all nurses review the NPA and 64B9 of the FAC .
To access the Nurse Practice Act go to: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0464/0464.html
To access the Florida Administrative Code 64B9 : Board of Nursing go to: https://www.flrules.org/gateway/organization.asp?id=332
American Nurses Association (ANA). (2010). Code of ethics for nurses with interpretive statements. Accessed November 1, 2018, https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
American Nurses Association (ANA). (2018). *Career & professional development resources.* Accessed November 1, 2018 https://www.nursingworld.org/resources/individual/
Florida Board of Nursing (FLBON). (2018). *Home index*. Accessed November 1, 2018, https://floridasnursing.gov/
Florida Board of Nursing (FLBON) *Nurse Compact FAQs* Accessed November 1, 2018 https://floridasnursing.gov/enhanced-nurse-licensure-compact-faqs/
Florida Center for Nursing (FCN). (2014). *Florida state workforce center*. Accessed November 1, 2018, https://www.flcenterfornursing.org
Florida Department of Health. (2018). *Practitioner profile.* Accessed November 1, 2018, http://www.floridahealth.gov/licensing-and-regulation/practitioner-profile/index.html
Florida Department of State. (N.D.). *Florida administrative code, division 64B9, board of nursing.* Accessed November 1, 2018, https://www.flrules.org/gateway/division.asp?DivID=332
Florida Legislature. (2018). *Florida statutes, title XXXII, Chapter 456, Health professions and occupations: general provisions.* Accessed November 1, 2018, http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0456/0456.html
Florida Nurses Association (FNA). (N.D.) *Florida Nurses Professional Organization.* Accessed November 1, 2018, http://www.floridanurse.org
Intervention Project for Nurses (IPN). (N.D.) *Promoting safe practices for Florida nurses.* Accessed November 1, 2018 https://ipnfl.org
National Council of State Boards of Nursing (NCSBN). (2018). *Nurse Practice act, rules, and regulations by state.* Accessed November 1, 2018 https://www.ncsbn.org/npa.htm
U.S. Constitution. (N.D.). *Constitutional topic*: *How a bill becomes law.* Accessed November 1, 2018 https://www.usconstitution.net/consttop_law.html
US Department of Health and Human Services. (N.D.). *HIPAA*. Accessed November 1, 2018 https://www.hhs.gov/hipaa/index.html
Appendix A: Legal Terms
Listed below are select terms defined in the Standards of Practice Relative to Registered Nurse or License Practical Nurse as well as legal terms discussed in the first part of the course.
- A voluntary act by which one person agrees to allow someone else to do something. For medical liability, consents must be in writing with an explanation of procedures to be performed.
- The transference to a competent individual the authority to perform a selected task or activity in a selected situation by a nurse qualified by licensure and experience to perform the task or activity.
- Communicating a plan of care to a LPN. Direction by an RN is not meant to imply the RN is supervising the LPN in the employment context.
- An obligation one has incurred or might incur through an act or failure to act.
- Licensed nurse:
- Either a registered nurse (RN) or licensed practical nurse (LPN) who holds a current valid license to practice nursing in Florida.
- Professional misconduct, improper discharge of professional duties, or failure to meet the standard of care, which results in harm to another.
- Nursing diagnosis:
- An identified patient need or problem that is amenable to nursing intervention. 464.003(15) defines it as “means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal.”
- Nursing process:
- The cyclic four to six step process used by professional nurses to provide care to patients: assessment, diagnosis, planning, implementation, and evaluation.
- Nursing task:
- Activities that constitute nursing practice, performed to maintain or improve the well being of patients who are unable to perform such actions for themselves.
- The recipient of nursing care, including an individual, group, or community.
- Res Ipsa Loquitur:
- Latin for "the thing speaks for itself". A doctrine of law applicable to cases where the defendant had exclusive control of the thing that caused the harm and where harm would NOT have ordinarily occurred without negligent conduct.
- Scope of practice:
- The range of knowledge, skills, and responsibilities of LPNs, RNs, and certified nursing specialties as identified and authorized by the Florida Board of Nursing.
- Standards of care:
- Guidelines for nursing practice as defined by state and federal laws, professional organizations, and employing institutions.
- A civil wrong that is intentional or unintentional.
- One who commits a tort.