In the previous exploration of competency, we discussed the governing bodies of nursing competency and ways that competency may be obtained and proven. When looking for effective, competent nurses there are varying factors to ask for and assess. Please note the below can be used by the criminal justice system when assessing competency BUT also will be looked at by a Board of Nursing when licensure is being investigated. (Some of these examples are extrapolated from witnessed interactions over many years, some details have been altered to make the examples less recognizable.)
- R.A. is a practicing SANE RN who performs approximately 15-20 exams a year at her facility. She attended 40-hour SANE training 8 years prior to the case being tried. This SANE is the one who did the exam and will be a fact witness.
Here are the things to consider when developing inquiry:
Overall nursing practice history is an important aspect to consider for R.A. Schooling, work history, required education. Nurses could have educational levels from an associate degree, bachelor’s degree, master’s, or doctorate degree. There are also post education certifications that nurses can have.
Membership to any professional organizations aid in the maintenance of competent practice for nurses. Medical Surgical Nurses have options to certify in med/surg nursing. Most nursing specialties have this option available to them. Outside specialties are things like forensic nursing, education, legal nurse consultant is a couple of examples. Specific activities which maintain competency as specifically a SANE RN (in this case), which allows the nurse keep up with changes in practice, and changes in scope and standards. Some of these activities may include continuing education courses, belonging a to professional organization provides opportunities to keep up with standards of practice, attending conferences, presenting to peers or creating content for educational purposes, publishing in a journal.
If the nurse is presenting something as fact (for example let’s say in this case, the nurse makes a statement such as “the vagina is 8 inches long”, where is the research that supports that assertion? The above statement may have been made in relation to discussing digital penetration and cervical injury. In taking the next step, it would be important to question what research discussing cervical injury and digital penetration. There should be a general idea of what the research is that this RN is using as if there is an opposing expert witness, they will surely have research backing their position.
- A.H. is a forensic nurse who has just moved to Oregon (from another state) and is performing SANE exams on patients at a hospital with limited resources and she is their first forensic nurse. A.H. is being investigated by the board of nursing after a complaint was made by a patient after the patient was told that the evidence from the kit, she was the victim is was mishandled by the SANE, so evidence cannot be used in her case.
Every state crime lab and state organization governing practice has their own standards and set of competencies, A.H. needs to have knowledge and understanding of this practice standards in the state where they are currently practicing. Along with the standards listed above, the nurse is also obligated to understand facility policy to support practices. This RN needs to be able to articulate what the facility policies state in regard to any limitations or requirements of SANE practice. (Please note, many facilities are turning to Policy and Procedure developed by Lippincott which are, in general broad, to guide nursing practice).
There is specialty equipment often utilized to collect and maintain isolation of forensic evidence. A.H. needs to ensure that this equipment is maintained by the facility to comply with standards of practice. If A.H. does not have access to this equipment there can be questions about how cross contamination of evidence collected was prevented. Deviation from standards of practice can be common in specific healthcare settings but there needs to be reasonable explanations as to why. For example, a standard of care of victims of violence is to allow as much control as possible throughout the exam. It is also a standard that the SANE collect vaginal swabs. To allow the patient a sense of control and provide a healing environment, the SANE (at the request of the patient and advocate) explains to the patient how to collect the swabs herself as she is not comfortable allowing the SANE to collect. This is a reasonable deviation from standard practice that is acceptable by multiple governing SANE practice organizations.
Please note that deviations from standards of practice are common throughout all of nursing practice but there should always be reasonable explanation and there should be charting that supports the deviation.
- V.G. is a mental health nurse who is under investigation by OSBN for patient neglect and violation of standards of practice. VG was the primary nurse for a patient experiencing postpartum psychosis and was admitted to the mental health floor. Head to toe assessments and documentation are an expectation of any nurse no matter what specialty they practice in if there is patient contact. V.G. performed a mental health assessment and documentation of that assessment on this patient but did not chart a full physical assessment therefore it is assumed one was not done. This specific patient was later in the shift diagnosis with sepsis from a wound infection of her cesarean site. The disciplinary action is based on the decompensation of the patient would have been avoided has the nurses fulfilled her scope and standard of practice.
Just because a patient is on a specialized unit (like a mental health unit) does not mean the nurse is not obligated to provide the patient full assessments to ensure the maintenance of holistic health. Standard protocol in facilities require assessments to be performed once a shift and a full set of vital signs a minimum of every 8 hours (depending on the unit). Every nurse (for this purposes of this example) is required by Oregon State Board of Nursing and American Nurses Assoc. under their license to provide competent care as required under the Scope and Standards definition by each governing organization, respectively. This patient (per protocol and standards) should be getting an assessment not just of her mental health symptoms, but of her overall health (to include a wound assessment) minimally once a shift. This assessment needs to be charted in a timely manner and per protocol any abnormal assessment findings need to be reported to the advanced provider (admitting provider) in a timely manner to provide the patient appropriate care needed.
Consider using Integrity Legal Nurse Consulting PDX for your medical negligence cases; our nurses have been thoroughly vetted and have the necessary experience to serve as testifying experts.
Helpful links:
- ANA Scope and Standards: Nursing Scope and Standards of Practice | ANA (nursingworld.org)
- Oregon Board of Nursing Scope and Standards Link [this link provides definitions of practice for disciplines including CNAs, LPNs, RN’s, Advanced Practice Nurses (this is a nurse practitioner)]: Oregon State Board of Nursing : Oregon Nurse Practice Act : State of Oregon
- Oregon SANE information: Oregon SATF SANE and SAE Program — Oregon SATF