Florida Nursing Laws and Rules
COURSE PRICE: $20.00
CONTACT HOURS: 2
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Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Florida Board of Nursing Accreditation #NCE3403.
Course Availability: Expires July 5, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Medical Disclaimer Legal Disclaimer Disclosures
This course fulfills the Florida Board of Nursing requirement for 2 contact hours on the laws and rules that govern the practice of nursing in Florida. We report course completions to CE Broker.
Florida Nursing Laws and Rules
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare Florida nurses to comply with the laws and rules that govern nursing practice in the state of Florida, including those from the Florida Statutes and Administrative Code.
Upon completion of this course, you will be able to:
- Describe the Florida Board of Nursing.
- Contrast the Florida Board of Nursing with nursing professional organizations and the Florida Nurses Association.
- Identify and describe the levels of nursing practice in Florida.
- Define the factors for safe delegation to unlicensed assistive personnel.
- Explain the requirements for renewing a nursing license in Florida.
- Differentiate between ethical and legal issues.
- Discuss Florida nursing law violations and disciplinary actions.
TABLE OF CONTENTS
The practice of nursing requires specialized knowledge, skill, and independent decision making. Nursing careers take widely divergent paths—practice focus varies by setting, by type of client, by different disease, therapeutic approach, or level of rehabilitation. Moreover, nurses are mobile and 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 poses a risk of harm to the public if practiced by professionals who are unprepared or incompetent, the state, through its police powers, is required to protect its citizens from harm. That protection is in the form of reasonable laws to regulate nursing (NCSBN, 2014).
Currently in each U.S. state and territory, a law known as a nurse practice act designates an authoritative body that defines and regulates the nursing practice of every nurse in every role. This authoritative body, known as a board of nursing, is 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.
This course discusses those standards for the state of Florida as written by the Florida Board of Nursing in accordance with the Florida Statutes and Administrative Code.
FLORIDA NURSING LAWS AND RULES
All states and territories have enacted a nurse practice act (NPA). Each state’s NPA is enacted by the state’s legislature. The NPA itself is insufficient to provide the necessary guidance for the nursing profession; therefore, each NPA establishes a board of nursing (BON) that has the authority to develop administrative rules or regulations to clarify or make the law more specific.
All NPAs include:
- Authority, power, and composition of a board of nursing
- 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
Florida Nurse Practice Act
In Florida, nursing standards are codified in the Florida Statutes (F.S.) and Florida Administrative Code (F.A.C.). The Florida Statues are a permanent collection of state laws organized by subject area into a code made up of titles, chapters, parts, and sections. The Florida Statutes are updated annually by laws that create, amend, transfer, or repeal statutory material (Florida Legislature, 2014c).
The Florida Nurse Practice Act is outlined in the Florida Statutes, Title XXXII, Chapter 464, Regulation of Professions and Occupations (Florida Legislature, 2014b). The sole legislative purpose of the NPA is to “ensure that every nurse practicing in this state 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.”
FLORIDA STATUTES, TITLE XXXII, CHAPTER 464
Part I. Nurse Practice Act
464.001 Short title
464.004 Board of Nursing; membership; appointment; terms
464.005 Board headquarters
464.006 Rulemaking authority
464.008 Licensure by examination
464.009 Licensure by endorsement
464.0115 Certification of clinical nurse specialists
464.012 Certification of advanced registered nurse practitioners; fees
464.013 Renewal of license or certificate
464.014 Inactive status
464.015 Titles and abbreviations; restrictions; penalty
464.016 Violations and penalties
464.017 Sexual misconduct in the practice of nursing
464.018 Disciplinary actions
464.019 Approval of nursing education programs
464.0195 Florida Center for Nursing; goals
464.0196 Florida Center for Nursing; board of directors
464.0205 Retired volunteer nurse certificate
464.027 Registered nurse first assistant
Part II. Certified Nursing Assistants
464.202 Duties and powers of the board
464.203 Certified nursing assistants; certification requirement
464.204 Denial, suspension, or revocation of certification; disciplinary actions
464.205 Availability of disciplinary records and proceedings
464.206 Exemption from liability
464.208 Background screening information; rulemaking authority
464.2085 Council on Certified Nursing Assistants
Florida Board of Nursing
The practice of nursing in Florida is licensed by the Florida Board of Nursing (BON), which is under the jurisdiction of the Florida Department of Health. The BON is funded and supported by mandatory licensure fees paid by nurses wishing to practice legally in the state of Florida.
The role of the Department of Health is outlined in the F.S. 456, Health Professions and Occupations (Florida Legislature, 2014a), which states that:
(Health) professions shall be regulated only for the preservation of the health, safety, and welfare of the public under the police powers of the state. Such professions shall be regulated when:
- Their unregulated practice can harm or endanger the health, safety, and welfare of the public, and when the potential for such harm is recognizable and clearly outweighs any anticompetitive impact that may result from regulation.
- The public is not effectively protected by other means, including, but not limited to, other state statutes, local ordinances, or federal legislation.
- Less restrictive means of regulation are not available.
The Florida Board of Nursing consists of 13 members. All members must be residents of the state of Florida. The board must consist of:
- Seven registered nurses who represent diverse fields and who have been engaged in the practice of professional nursing for at least four years, including at least:
- One advanced registered nurse practitioner
- One nurse educator member of an approved program
- One nurse executive
- Three practical nurses who have practiced for at least four years prior to their appointment
- Three members who have never been licensed nurses and who are in no way connected with the practice of nursing
The members are appointed by the governor for terms of four years.
The NPA authorizes the Florida Board of Nursing to make and enforce rules and regulations for registered nurses, practical nurses, certified nurse assistants, certified nurse-midwives, nurse practitioners, clinical nurse specialists, registered nurse first assistants, and certified registered nurse anesthetists (Florida Statutes, 2014b).
The BON “licenses, monitors, disciplines, educates, and, when appropriate, rehabilitates its licensees to assure their fitness and competence in providing healthcare services for the people of Florida” (FLBON, 2014). They are responsible for enacting the rules outlined in the Florida Administrative Code.
Florida Nursing Rules
The Florida Administrative Code is the official compilation of administrative rules for the state of Florida. The Department of State oversees the publishing of the F.A.C. and updates it weekly (Florida Department of State, 2010b). Chapter 64B9 of the F.A.C. outlines rules related to nursing.
FLORIDA ADMINISTRATIVE CODE, DIVISION 64B9
64B9-2 Nursing programs
64B9-3 Requirements for licensure
64B9-4 Administrative policies pertaining to certification of advanced registered nurse practitioners
64B9-5 Continuing education requirements
64B9-6 Inactive status and reactivation of inactive license
64B9-8 Hearings, proceedings, conferences, discipline
64B9-9 Impaired nurse program
64B9-11 Maintenance of medical records
64B9-12 Administration of intravenous therapy by licensed practical nurses
64B9-13 Home hemodialysis treatments
64B9-14 Delegation to unlicensed assistive personnel
64B9-15 Certified nursing assistants
64B9-16 LPN supervision in nursing home facilities
64B9-17 Role of the registered nurse in conscious sedation
Source: Florida Department of State, 2010a.
Florida Center for Nursing
The Florida Center for Nursing is distinct from the Board of Nursing and, as outlined in the Nurse Practice Act, was formed to “address issues of supply and demand for nursing, including issues of recruitment, retention, and utilization of nurse workforce resources” (Florida Legislature, 2014b).
[The Florida Center for Nursing] is a state workforce center established in Florida Statute (F.S. 464.0195) to recommend solutions to address Florida’s nursing shortage. [It] is here to inform, educate, and update you on nursing shortage issues and solutions. By collecting, analyzing, and reporting on the nursing workforce, the Center seeks to ensure an adequate supply of direct care providers for the health of all Floridians (FCN, 2014).
The Center has a separate board of directors and is partly funded by fees imposed at the time of licensure and licensure renewal.
One of the hallmarks of a profession is that its members band together in collegial association to provide a variety of services for its members. These services include such things as continuing education, collective bargaining, legislative advocacy, and information about the profession. These organizations are not set up by state laws or through the government.
In Florida, professional associations include the Florida Nurses Association and state chapters of other specialty associations such as those for nurse practitioners. Typically, associations are run by boards of trustees elected by members who pay voluntary membership dues.
The mission of professional associations is characterized by that of the Florida Nurses Association: “To serve and support all registered nurses through professional development, advocacy, and the promotion of excellence at every level of professional nursing practice” (FNA, 2012).
The primary difference between the Florida Board of Nursing and professional organizations is that professional organizations have no legal authority, whereas the Florida Board of Nursing has authority because it was established by the Nurse Practice Act with the unambiguous function of promoting and protecting the health of citizens through safe nursing practice.
LEVELS OF NURSING PRACTICE IN FLORIDA
The practice of nursing is regulated by the state in order to protect members of the public who need nursing care. Safe, competent nursing practice is grounded in the law as written in the state’s Nurse Practice Act and its rules. Because nursing is a dynamic practice, questions may arise about whether certain tasks are within the nurse’s scope of practice. All nursing care should be consistent with the nurse’s preparation, education, experience, knowledge, demonstrated competency, and the laws and rules governing nursing.
A licensed practical nurse (LPN) means any person licensed in Florida to practice practical nursing. The practice of practical nursing is the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others.
Practical nursing must be performed under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and accountable for making decisions that are based on his or her educational preparation and experience in nursing (Florida Legislature, 2013b).
[This section is taken from F.A.C. 64B9-12, Administration of intravenous therapy by licensed practical nurses (2010).]
As medical science advances and the demands for healthcare in Florida grow, the scope of nursing practice in general and of the practice of practical nursing in particular is expanding. It has become necessary that the licensed practical nurse, when qualified by training and education and when approved by the institution at which the licensed practical nurse is employed, engage in the limited administration of intravenous therapy both to serve the public and to allow the professional nurse to better perform those acts requiring specialized nursing knowledge, judgment, and skill.
The purpose of the administrative code rule related to administration of intravenous therapy by LPNs is to protect the public by ensuring the availability of intravenous therapy and its competent administration in the care of the ill, injured, or the infirm. In keeping with the purpose, this rule authorizes the qualified licensed practical nurse to administer those aspects of intravenous therapy within the scope of practice of the licensed practical nurse, enumerates those aspects of intravenous therapy outside the scope of practice of the licensed practical nurse, and sets out the educational and/or competency verification necessary to administer, under direction, limited forms of intravenous therapy.
The administration of intravenous therapy is the therapeutic infusion and/or injection of substances through the venous peripheral system, consisting of activity which includes: observing, initiating, monitoring, discontinuing, maintaining, regulating, adjusting, documenting, planning, intervening, and evaluating.
Aspects of intravenous therapy which are outside the scope of practice of the licensed practical nurse unless under the direct supervision of the registered professional nurse or appropriate physician (as outlined above) and which shall not be performed or initiated by licensed practical nurses without direct supervision include the following:
- Initiation of blood and blood products
- Initiation or administration of cancer chemotherapy
- Initiation of plasma expanders
- Initiation or administration of investigational drugs
- Mixing IV solution
- IV pushes, except heparin flushes and saline flushes
Although this rule limits the scope of licensed practical nurse practice, it is appropriate for licensed practical nurses, under direct supervision, to care for patients receiving such therapy.
“UNDER THE DIRECTION” VERSUS “DIRECT SUPERVISION”
It is important to note that “under the direction of a registered professional nurse” means that the registered professional nurse has delegated intravenous therapy functions to a qualified licensed practical nurse. The registered professional nurse does not in all instances have to be on the premises in order for the licensed practical nurse to perform the delegated functions.
This must be distinguished from “direct supervision,” which means on the premises and immediately physically available.
Tanya is an LPN with five years’ experience who has recently moved from Indiana to Florida. This is her first shift on a surgical floor following orientation, and she is responsible for five patients who are 1- to 4-days post-op. A new order has been written for Mr. Hansen, who is anemic. The order is for 2 units PRBCs.
Tanya is uncertain whether she is allowed to carry out this order in Florida. She goes to the Florida Administrative Code website and reads Division 64B9, Chapter 12, which describes the role of the LPN in intravenous therapy procedures. There she finds that initiation of blood or blood products by an LPN may be performed only under the direct supervision of an RN.
The task is not within her legal scope of practice in Florida unless she is supervised, so Tanya requests her charge nurse, an RN, supervise her initiation of the blood. Her charge nurse agrees, and they review the order together and prepare to initiate the transfusion.
SUPERVISION IN NURSING HOME FACILITIES
[This section is taken from F.A.C. 64B9-16, LPN supervision in nursing home facilities (2010).]
Licensed practical nurses may supervise certified nursing assistants (CNAs) and unlicensed personnel (UP) in nursing home facilities pursuant to F.A.C. 64B9-16. The LPN, however, must complete a minimum 30-hour, post-basic supervisory education course (or a supervisory course at a post-graduate level) and demonstrate a work history of no less than six months of full-time clinical nursing experience in a hospital or nursing home. A registered nurse must provide supervision to the LPN.
Unlicensed personnel (UP) are defined as persons who do not hold licensure from the Division of Health Quality Assurance of the Department of Health but who have been assigned to function in an assistive role to registered nurses or licensed practical nurses in the provision of patient care services through regular assignments or delegated tasks or activities and under the supervision of a nurse.
The tasks delegated by the LPN to the CNA or UP in a nursing home facility must be based on the following:
- The task/activity is within the area of responsibility of the nurse delegating the task
- The task/activity is within the knowledge, skills, and ability of the nurse delegating the task
- The task/activity is of a routine, repetitive nature and shall not require the CNA or UP to exercise nursing knowledge, judgment, or skill
- The CNA or UP can and will perform the task/activity with the degree of care and skill that would be expected of the nurse
The tasks not to be delegated by the LPN include:
- Any activity that is outside the scope of practice of the LPN; or in which the Nurse Practice Act stipulates that the LPN must have direct supervision of a registered nurse in order to perform the procedure
- Those activities for which the licensed practical nurse, certified nursing assistant, or UP has not demonstrated competence
[This section is taken from F.S. 464.003, Definitions.]
A registered nurse (RN) means any person licensed in Florida to practice professional nursing. 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 be limited to:
- 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
- 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
- The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection
A professional nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.
A nursing diagnosis is defined as 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 diagnosis is in the scope of practice of the registered nurse and defines his/her role. A nursing treatment is the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health.
[This section is taken from F.S. 464.003, Definitions; F.S. 464.012, Certification of advanced registered nurse practitioners, fees; F.S. 464.0115, Certification of clinical nurse specialists; and F.S. 464.027, Registered nurse first assistant (2013b).]
ADVANCED REGISTERED NURSE PRACTITIONER
An advanced registered nurse practitioner (ARNP) means any person licensed in Florida to practice professional nursing and certified in advanced or specialized nursing practice, including certified registered nurse anesthetists, certified nurse midwives, and nurse practitioners.
Within the context of advanced or specialized nursing practice, the advanced registered nurse practitioner may perform acts of nursing diagnosis and nursing treatment of alterations of health status. The advanced registered nurse practitioner may also perform acts of medical diagnosis and treatment, prescription, and operation defined by the Board of Nursing and his/her specialty.
Advanced registered nurse practitioners include certified registered nurse anesthetists, certified nurse midwives, and nurse practitioners. Within the established framework, an advanced registered nurse practitioner may:
- Monitor and alter drug therapies
- Initiate appropriate therapies for certain conditions
- Order diagnostic tests and physical and occupational therapy
Certified Registered Nurse Anesthetist
In addition to the above, 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, which 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 healthcare management of the patient
- Support life functions during anesthesia healthcare, 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
The certified nurse midwife may, to the extent authorized by an established protocol which has been approved by the medical staff of the healthcare 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
The nurse practitioner may perform any or all of the following acts within the framework of established protocol:
- 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
CLINICAL NURSE SPECIALIST
A clinical nurse specialist (CNS) means any person licensed in Florida to practice professional nursing and certified in nurse specialist practice. Clinical nurse specialist practice is the delivery and management of advanced practice nursing care to individuals or groups, including the ability to:
- Assess the health status of individuals and families using methods appropriate to the population and area of practice
- Diagnose human responses to actual or potential health problems
- Plan for health promotion, disease prevention, and therapeutic intervention in collaboration with the patient or client
- Implement therapeutic interventions based on the nurse specialist’s area of expertise and within the scope of advanced nursing practice, including, but not limited to, direct nursing care, counseling, teaching, and collaboration with other licensed healthcare providers
- Coordinate healthcare as necessary and appropriate and evaluate with the patient or client the effectiveness of care
CERTIFIED REGISTERED NURSE FIRST ASSISTANT
Florida Statutes encourage the use of RN first assistants who meet the qualifications as “assistants at surgery” by physicians and hospitals to provide quality, cost-effective surgical intervention to healthcare recipients in the state.
Registered nurse first assistants meet the qualifications listed in F.S. 464.027 (Florida Legislature, 2013b):
- RN licensure
- Certification in perioperative nursing
- Certificate from, and successful completion of, a recognized program (a recognized program addresses all content of the Association of periOperative Registered Nurses’ Core Curriculum for the Registered Nurse First Assistant, and includes one academic year, defined as 45 hours of didactic instruction and 120 hours of clinical internship or its equivalent of two college semesters)
Each healthcare institution must establish specific procedures for the appointment and reappointment of registered nurse first assistant staff members and for granting, renewing, and revising their clinical privileges.
Practice of Certified Nursing Assistants
[This section is taken from F.S. 464.201, Definitions; F.S. 464.203, Certified nursing assistants: certification requirement (2013b); and F.A.C. 64B9-15 (2010).]
A certified nursing assistant (CNA) means a person who meets the qualifications specified in the Florida Statutes and who is certified by the BON as a certified nursing assistant. The practice of a certified nursing assistant means providing care and assisting persons with tasks relating to the activities of daily living. Such tasks are those associated with:
- Personal care
- Maintaining mobility
- Nutrition and hydration
- Toileting and elimination
- Assistive devices
- Safety and cleanliness
- Data gathering
- Reporting abnormal signs and symptoms
- Postmortem care
- Patient socialization and reality orientation
- End-of-life care
- Cardiopulmonary resuscitation and emergency care
- Residents’ or patients’ rights
- Documentation of nursing-assistant services
A comprehensive list of authorized duties for the certified nursing assistant is available in the F.A.C. 64B9-15 (2010).
DELEGATION TO UNLICENSED ASSISTIVE PERSONNEL
[This section is taken from F.A.C. 64B9-14, Delegation to unlicensed assistive personnel.]
Registered nurses and LPNs must follow the rules from the Florida Administrative Code when delegating tasks to unlicensed assistive personnel (UAPs). UAPs are persons who do not hold licensure from the Division of Health Quality Assurance of the Department of Health but who have been assigned to function in an assistive role to registered nurses or licensed practical nurses in the provision of patient-care services. Examples of UAPs are CNAs, home health aides, patient care technicians, surgical assistants, and patient care assistants.
When the RN or LPN is delegating, he or she must use nursing judgment to consider the suitability of the task or activity to be delegated. Factors to weigh in selecting the task or activity include:
- Potential for patient harm
- Complexity of the task
- Predictability or unpredictability of outcome, including the reasonable potential for a rapid change in the medical status of the patient
- Level of interaction required or communication available with the patient
- Resources both in equipment and personnel available in the patient setting
Factors to weigh in selecting and delegating to a specific delegatee include:
- Normal assignments of the UAP
- Validation or verification of the education and training of the delegate
The delegation process shall include communication to the UAP that 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 assignment, verification of monitoring, and supervision.
Initial allocation of the task or activity to the delegatee, periodic inspection of the accomplishment of such task or activity, and total nursing care responsibility remains with the qualified nurse delegating the tasks or assuming responsibility for supervision.
Delegation of Tasks Prohibited
The registered nurse or licensed practical nurse, under direction of the appropriate licensed professional as defined in F.S. 464.003(3)(b), shall not delegate:
- Those activities not within the delegating or supervising nurse’s scope of practice
- Nursing activities that include the use of the nursing process and require the special knowledge, nursing judgment, or skills of a 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
- Evaluation of progress in relationship to the plan of care
- Those activities for which the UAP has not demonstrated competence
Sabrina is an RN in a busy medical-surgical department at a hospital in Miami. She is in the middle of passing morning medications when her new post-op patient, Mr. Winters, rings in complaining of severe pain. When she arrives to Mr. Winters’ room, Sabrina performs a focused assessment of his surgical dressing and finds everything within normal limits. Sabrina consults the electronic medication administration record (eMAR) and sees that Mr. Winters has IV morphine ordered for severe pain. She also recalls the report from the PACU nurse stating that Mr. Winters’ blood pressure was running low.
In reviewing the tasks at hand, Sabrina knows she needs to continue with medications for her other patients, to get a new set of vitals on Mr. Winters to be sure his blood pressure won’t bottom out with a new dose of IV morphine, and then to administer the pain medication to Mr. Winters. In order to accomplish her tasks in a timely manner, Sabrina determines that it is necessary to delegate something to the appropriate assistive personnel. She remembers that Martha, a CNA, has also been assigned to her patients.
Sabrina contacts Martha to see if she is available to take Mr. Winters’ blood pressure, knowing that taking patients’ vitals is within Martha’s education and training and is part of her normal assignment as a CNA. Sabrina indicates to Martha that she will continue passing medications while Martha gets the patient’s vitals, which she should carry out right away. Sabrina informs Martha that she will be with the patient in the next room by the time Martha has the vital signs. Martha agrees and begins to take Mr. Winters’ blood pressure.
Martha finds Sabrina as she is coming out of the room next door and reports that Mr. Winters’ blood pressure is 118/58, which presents no contraindication to administering the IV morphine. Sabrina goes to the department’s med room to obtain the pain medication and administers the morphine, relieving Mr. Winters’ pain. She thanks Martha for her help and then returns to her other patients.
LICENSURE RENEWAL REQUIREMENTS
[This section is taken from F.A.C. 64B9-1, Organization; F.A.C. 64B9-5, Continuing education requirements; F.A.C. 64B9-6, Inactive status and reactivation of inactive license; and F.A.C. 64B9-7, Fees.]
Florida nursing licenses are monitored by the Florida Board of Nursing and required to be renewed every two years.
During each biennium, one contact hour of continuing education must be earned for each calendar month of the licensure cycle. Those persons licensed by examination within a biennium are exempt from the continuing education requirement for that biennium. A registered nurse who also holds a current license as a licensed practical nurse may satisfy the continuing education requirement for renewal of both licenses by completing appropriate continuing education for a registered nurse. A licensee is exempt from continuing education requirements at the time of renewal if the licensee was on active duty with the Armed Forces within six months of the renewal date.
The licensee shall retain for four years certificates of attendance and other records to document the completion of the continuing education requirement. The BON will audit at random a number of licensees as is necessary to assure that the continuing education requirements are met. Failure to document compliance with the continuing education requirements or the furnishing of false or misleading information regarding compliance shall be grounds for disciplinary action.
All licensees must complete a two-hour course on prevention of medical errors, which meets the criteria of F.S. 456.013 as part of the total hours of continuing education required for initial licensure and biennial renewal. Beginning with the biennium ending in 2015, each licensee shall complete a two-hour course on the laws and rules that govern the practice of nursing in Florida.
Fees and Status
Fees are due to the BON at the time of renewal. Fee amounts may be found in F.A.C. 64B9-7.001 (Florida Department of State, 2010a).
Each person holding a license issued pursuant to F.S. 464 must maintain on file with the Board of Nursing the current address at which any notice required by law may be served by the Board or its agent. Within 60 days of changing this address, whether or not within this state, the licensee shall notify the Board in writing of the new address at which the licensee may be served with notices or other documents. Each person holding a license issued pursuant to F.S. 464 must maintain on file with the Board of Nursing the current place of practice. Places of practice include acute care facilities, long-term care facilities, rehabilitation facilities, clinics, physicians’ offices, home health care agencies, and educational institutions, among others.
A license to practice nursing which is not renewed at the end of the prescribed biennium shall automatically revert to delinquent status. To renew the license, the licensee must demonstrate completion of all continuing education required by F.A.C. 64B9-5 and must pay the delinquency fee prescribed in F.A.C. 64B9-7.001.
A licensee may apply to the Department to place his license on inactive status. The application shall be made on forms provided by the Board and shall be accompanied by an application fee for inactive status in the amount specified in F.A.C. 64B9-7.001. Applications for inactive status will be considered by the Department only during the biennium license renewal period.
Pursuant to F.S. 464.016(1)(a), it is unlawful to practice nursing with an inactive or delinquent license.
ETHICS VERSUS LAWS
Nurses practice within a society governed by laws. Nurses also follow ethical standards of care at all times. Thus, nurses need to understand the basis of law (jurisprudence) in the United States and the relationship of law to ethics in the practice of nursing.
Ethical principles serve as general guides for behavior. In contrast, laws flow from ethical principles and consist of rules about specific situations. These rules are enforced by an authority with the power to see that they are obeyed.
Many people roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons, especially healthcare providers such as nurses.
Ethics is a branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Because ethics assumes that people have the ability to make choices about their behavior, it has been the subject of philosophical discussion for centuries, generating an enormous body of literature.
Prescriptive ethics offers advice about the way people decide what is good or bad behavior, doing so from two different perspectives: teleological and deontological.
A teleological (consequential, utilitarian, situational) perspective affirms that the rightness or wrongness of an act is determined by the end results of an action. The term comes from the Greek teleos, meaning “end.” If the end result harms others, the act is considered wrong or bad. If the end result benefits others, the act is considered good or right. Teleological theories foster morality by developing the capacity of humans to make choices. These theories reject fixed moral rules of conduct such as the biblical command “Thou shalt not kill” (Exodus 20:13).
For example, a man is suffering with intractable pain caused by an incurable disorder. He begs his physician to perform a surgical procedure that will relieve his suffering but might hasten his death. According to teleological perspective, the physician should perform the surgery because the end result (relieving pain) is a greater good than keeping the man alive longer with intractable pain.
The deontological (nonconsequentialist) perspective fosters morality by teaching humans to accept and obey fixed laws. The term comes from the Greek deontos, meaning “duty to obey.” Deontological ethics maintains that certain acts are inherently right or wrong, regardless of the situation or the end results. Thus, the deontological perspective simplifies ethical decision-making by removing the issue of mitigating circumstances.
According to this perspective, preserving the life of the man with intractable pain is a greater good than relieving his pain and hastening his death. The physician’s duty is to obey the commandment “Thou shalt not kill” regardless of the situation or end results (Hamilton, 1996).
Ethical principles are fundamental concepts by which people make decisions. These principles serve as criteria against which people measure behavior. Five ethical principles mark the practice of healthcare professionals: 1) respect for human life and dignity, 2) beneficence, 3) autonomy, 4) honesty, and 5) justice.
Respect for human life and dignity is one of the most basic of ethical principles. It asserts that “individuals must be treated as unique beings, equal to every other individual” (Rawls, 1999). When applied to nursing, respect for human life and dignity means nurses:
- Refrain from abuse, harassment, or discrimination
- Respect the personhood, lifestyle, and belief system of patients
- Demonstrate regard for patients’ physical, psychological, and socioeconomic well-being
- Strive to sustain human life and dignity
- Respect and hold in confidence all personal information
- Require specific legal justification for interference with a patient’s civil liberties
Beneficence means doing good for the benefit of others and maintaining professional competence. The concept of nonmaleficence is closely associated with beneficence and says that if one cannot do good, then he or she should at least do no harm. Ideally, it means acting in ways that demonstrate care and nurturance. When applied to practice, beneficence means nurses:
- Relate to patients professionally and objectively
- Follow treatment plans in consultation with other clinicians
- Choose the option that will do good and avoid harm
- Recognize that under certain conditions beneficence overrides autonomy and that compulsory treatment may be justified
Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out that choice. Nurses carry out the principle of autonomy by providing accurate, scientific information to patients and assisting them to understand the information and make decisions based on it. When applied to practice, autonomy means nurses:
- Make sure patients understand available options regarding their treatment
- Respect and accept decisions patients make about their own care or the care of another person for whom they are legally responsible
- Implement and evaluate interventions chosen by patients
- Respect and hold in confidence personal information of patients, divulging it only when patients or their legal guardians give permission
Honesty (veracity) means being truthful in word and deed, even when conveying unwelcome information about a condition or treatment. Nurses must be truthful yet compassionate, withholding information only when the patient is a minor child or an adult with a legal guardian. When applied to practice, honesty means nurses:
- Accurately report and record critical data
- Place the welfare of patients above personal or professional gain
- Keep promises and abide by contracts
- Provide factual, scientific, and relevant information about treatment, including benefits and risks
Justice implies fairness and equality and requires impartial treatment of patients. Like other ethical principles, justice is based on respect for human life and dignity. The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources will be distributed equally, using the same criteria for everyone. When applied to practice, justice means nurses:
- Assess all patient needs with equal diligence and professionalism
- Attend to the needs of patients, without prejudice according to their personality, disability, race, religion, gender, age, or lifestyle
- Evaluate and communicate information about plans of care without bias
- Deal fairly and equally with professional supervisors, colleagues, and subordinates
To help people examine their lives and clarify their values, Louis Raths (1979) suggested a three-tier, seven-step process that he called “values clarification.”
- Identify and select alternatives
- Choose freely from alternatives
- Consider the consequences of each choice
- Be proud of and happy in your choice
- Affirm your choice publicly
- Make the choice a part of your behavior
- Act with a pattern of consistency and repetition
Source: Modified from Raths et al., 1979.
Sara, a registered nurse, works in a busy medical-surgical department at a healthcare facility located in a conservative Christian community. Recently, she converted to Islam. As a testament to her newfound faith, she decided to wear the traditional headscarf, called a hijab, at work. Her employment contract upheld her right to cover her head as long as it did not interfere with her duties as a nurse. Some of her patients, however, were offended by the headscarf and saw Sara as traitor to the United States and a supporter of Muslim terrorists. Several of her coworkers agreed with the patients, felt the same hostility toward Sara, and complained to their supervisor. The supervisor discussed the issue of values with Sara and helped her use Raths’ seven-step process to decide what to do.
- Identify and select alternatives
Sara considered the situation. Sara felt that the attitudes of those who criticized her demonstrated intolerance and an ignorant view of Islam, which conflicted with her own values of tolerance and understanding. Out of principle or to take a stand, she could continue to wear the hijab. She could also quit work at this facility and hope to find a job in a more tolerant environment where she could wear the hijab without censure. Or she could stop wearing the hijab at work.
- Choose freely from the alternatives
- Consider the consequences of each choice
Sara realized that continuing to wear the hijab would surely continue to offend some patients and coworkers and create a hostile work environment for her. Likewise, while there are other RN positions available in the area, no matter where she were to work in this community, some of her patients and coworkers would probably have the same response to her wearing the hijab. On the other hand, she was concerned that failure to wear the hijab might go against the teachings of her new faith.
To help her make her choice, Sara consulted the imam at the mosque where she worships. He explained that the Qur’an, the holy book of Islam, does not command women to wear the hijab; it says “believing women should lower their gaze and guard their modesty” (Qur’an 24:31). Sara was relieved to learn that she was not required to wear the hijab. While she did not agree with the attitude of those who criticized her, she loved her current job and did not want to leave. She decided she would stop wearing the hijab but always dress and behave modestly.
- Be proud and happy about your choice
- Publically affirm your choice
Sara announced her decision to her supervisor and coworkers. She explained that since wearing the hijab is not required by her religion, she would stop wearing it to work. She expressed her wish to contribute to a tolerant and respectful workplace. Finding a way to practice her new faith without having to constantly address prejudice and misunderstanding made Sara proud and happy.
- Make the choice a part of your behavior
- Act with a pattern of consistency and repetition
Sara ceased wearing a hijab to work. Instead, she wore it when she went to functions with other Muslims. She adopted a modest demeanor at work and strove to exemplify her values through how she cared for her patients and related to her coworkers.
A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle.
Resolution of ethical dilemmas requires careful evaluation of all the facts of a case, including applicable laws, consultation with all concerned parties, and appraisal of the decision makers’ ethical stance (teleological end results or deontological fixed laws).
Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision makers resolve ethical dilemmas. Often these committees use an ethical decision-making process such as the following:
- Gather relevant facts about the patient’s age, diagnosis, advanced healthcare directive, and applicable laws.
- Identify and clearly state proposed actions together with the ethical principles represented by each proposed action.
- Determine who can make the decision and assist the person or persons to make it.
- Provide emotional support for everyone involved in resolving the dilemma.
ADVANCE HEALTHCARE DIRECTIVES
To reduce the number and complexity of ethical dilemmas, and in support of the ethical principle of autonomy, the Joint Commission on Accreditation of Healthcare Organizations (2011) recommends that all adults discuss their wishes regarding extraordinary treatment measures with their families, sign a legal document called an advance healthcare directive, and appoint someone to make healthcare decisions in their stead if they should become incapacitated.
Victoria, a 48-year-old woman with a long-standing manic disorder, built a fire on her living room floor, and when her husband tried to extinguish the fire, she attempted to stab him with a knife. She was taken by police to the emergency department and admitted involuntarily for treatment, where she accepted medications to help her sleep but declined to take any mood-stabilizing drugs. She said, “They make me feel like I’m moving in slow motion, going through Jell-O. I can’t stand them.”
The healthcare team recognized the dilemma between the three ethical principles of beneficence (providing treatment), autonomy (right of self-determination), and respect for human life and dignity (equal treatment).
In Victoria’s case, a crisis situation, it was readily accepted that treatment with medications was clinically indicated and likely to be of benefit (beneficence). They also recognized that Victoria has significant mental illness and her ability to make informed decisions was seriously impaired (autonomy). The decision to involuntarily commit her was based on dangerousness evidenced by the attempt to stab her husband. Equal treatment would require Victoria to be charged with a criminal act (respect for human life and dignity). Instead, Victoria was court-ordered to be detained and started on lithium, 600 mg per day, in three divided doses.
CODES OF ETHICS
Codes of ethics are formal statements that set forth standards of ethical behavior for members of a group. In fact, one of the hallmarks of a profession is that its members subscribe to a code of ethics. Every member of a profession is expected to read, understand, and abide by the ethical standards of its occupation.
In order to make explicit the values and standards of nurses, the American Nurses Association publishes a Code of Ethics for Nurses with Interpretive Statements. This document is regularly revised and updated by ANA, with the latest update to the code made in 2010 (see box below).
ANA CODE OF ETHICS OVERVIEW
Provision 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
Provision 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
Provision 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
Provision 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
Provision 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
Provision 6. The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action.
Provision 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
Provision 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
Provision 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Source: ANA, 2010.
Laws and Rules
Laws flow from ethical principles and are limited to specific situations and codified by detailed language. Laws establish rules of conduct and are formulated by an authority with power to enforce them. As such, laws change with time and circumstances.
The state of Florida has the power to create and enforce laws governing the profession of nursing, including licensure. In the states, the division of power mirrors that of the federal government:
- The legislative branch makes laws on behalf of the people.
- The judicial branch interprets these laws and adjudicates disputes, fulfilling its purpose to administer justice without partiality.
- The executive branch administers and enforces the laws, using the police power of the state.
|Source||Laws passed by legislative bodies of federal, state, and local governments||Executive powers, delegated by the legislative branch|
|Functions||Protects and provides for the general welfare of society||Carries out special duties of various agencies|
|Example||The Florida legislature passed the Nurse Practice Act, which is outlined in the Florida Statutes, Title XXXII, Chapter 464, Regulation of Professions and Occupations||The Florida Department of State maintains statewide rules for nurses, which are outlined in the Florida Administrative Code, Division 64B9, Board of Nursing|
DISCIPLINE RELATED TO NURSING PRACTICE
[This section is taken from F.A.C. 64B9-8, Hearings, proceedings, conferences, discipline, and F.S. 456.072, Disciplinary actions.]
Violations of nursing laws and rules can result in citations, denial of licenses, or disciplinary action.
The Florida Board of Nursing protects the public’s health and welfare by overseeing and ensuring the safe practice of nursing. It regulates and oversees nursing practice by enforcing the nursing laws of Florida. Violations of the Florida law related to nursing (F.A.C. 64B9 and F.S. 456 and 464) are serious and may result in complaints being filed and in discipline by the Board of Nursing (NCSBN, n.d.)… .
The BON utilizes its authority to decide whether misconduct or unsafe practice has occurred and what action should be taken. Violations are taken very seriously since they can put patients at risk. This is why every nurse is responsible for understanding his/her scope of practice and other requirements outlined in the law (NCSBN, n.d.).
Violations of Florida law that may result in citations include, but are not limited to:
- False, deceptive, or misleading advertising
- Improper use of a nursing title
- Unprofessional conduct (see below)
- Issuance of a worthless bank check to the Department or to the Board
- Failure to report address change
- Failure to pay a Board-ordered administrative fine by the time ordered
- Failure to complete a Board-ordered continuing education course by the time ordered
- Failure when requested to document full compliance with the continuing education requirements
- Failure to submit updates of required information in practitioner profile within 15 days after the final activity that renders such information a fact
- Providing to another individual a confidential password, access code, keys, or other entry mechanisms, which results in a violation of, or threatens, the integrity of a medication administration system or an information technology system
Citations result in monetary penalties as outline in F.A.C. 64B9-8 (Florida Department of State, 2010a).
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
Denial of a License or Disciplinary Action
According to Florida Statute, the following partial list of acts constitute grounds for denial of a license or disciplinary action for all health professions outlined in the aforementioned statute:
- Procuring, attempting to procure, or renewing a license to practice nursing by bribery, by knowing misrepresentations, or through an error of the Department or the Board
- Having a license to practice nursing revoked, suspended, or otherwise acted against, including the denial of licensure, by the licensing authority of another state, territory, or country
- Being convicted or found guilty of, or entering a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction which directly relates to the practice of nursing or to the ability to practice nursing
- Being found guilty, regardless of adjudication, of any of the following offenses:
- Forcible felony
- Theft, robbery, and related crimes
- Fraudulent practices
- Lewdness and indecent exposure
- Assault, battery, and culpable negligence
- Child abuse, abandonment, neglect, and exploitation
- Domestic violence
- Making or filing a false report or record, which the licensee knows to be false, intentionally or negligently failing to file a report or record required by state or federal law, willfully impeding or obstructing such filing or inducing another person to do so
- False, misleading, or deceptive advertising
- Unprofessional conduct, as defined by board rule
- Engaging or attempting to engage in the possession, sale, or distribution of controlled substances
- Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition
- Failing to report to the department any person who the licensee knows is in violation of this part or of the rules of the Department or the Board
- Failing to meet minimal standards of acceptable and prevailing nursing practice, including engaging in acts for which the licensee is not qualified by training or experience
Disciplinary action may take the form of citations, fines, probation, suspension, or revocation of licenses. For more information, see F.A.C. 64B9-8 (Florida Department of State, 2010).
Intervention Project for Nurses (IPN)
As part of a disciplinary process or separate from it, the mission of Intervention Project for Nurses is to “ensure public health and safety by providing an avenue for swift intervention/close monitoring and advocacy of nurses whose practice may be impaired due to the use, misuse, or abuse of alcohol or drugs, or a mental and/or physical condition. IPN is authorized by F.S. 464 and 456, to assist those nurses whose practice is affected” (IPN, 2014a).
The program’s objectives are as follows:
- To ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice, due to the use of drugs including alcohol and/or psychiatric, psychological, or a physical condition (F.S. 455.261)
- To provide a program for affected nurses to be rehabilitated in a therapeutic, non-punitive, and confidential process
- To provide an opportunity for retention of nurses within the nursing profession
- To facilitate early intervention, thereby decreasing the time between the nurse’s acknowledgment of the problem and his/her entry into a recovery program
- To require the nurse to withdraw from practice immediately and until such time that the IPN is assured that he/she is able to safely return to the practice of nursing
- To provide a cost-effective alternative to the traditional disciplinary process
- To develop a statewide resource network for referring nurses to appropriate services
- To provide confidential consultations for Nurse Managers
The Florida laws related to nursing are in place to define the Board of Nursing which then, along with the law itself, sets the standards of competent nursing practice and standards for promoting patient safety. By so doing, the mission of the Board of Nursing to promote and protect the health of citizens through safe nursing practice is achieved.
CE Broker (Official CE tracking system for Florida)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Nurses Association (ANA). (2010). Code of ethics for nurses with interpretive statements. Retrieved from http://www.nursingworld.org
Florida Board of Nursing (FLBON). (2014). Retrieved from http://floridasnursing.gov
Florida Center for Nursing (FCN). (2014). Retrieved from http://www.flcenterfornursing.org
Florida Department of State. (2010a). Florida administrative code, division 64B9, board of nursing. Retrieved from https://www.flrules.org
Florida Department of State. (2010b). Learn about rulemaking. Retrieved from https://www.flrules.org
Florida Legislature. (2014a). (2013a). 2013 Florida statutes, title XXXII, chapter 456, health professions and occupations: general provisions. Retrieved from http://www.leg.state.fl.us
Florida Legislature. (2014b). 2013 Florida statutes, title XXXII, chapter 464, nursing. Retrieved from http://www.leg.state.fl.us
Florida Legislature. (2014c). Online Sunshine: statutes and constitution. Retrieved from http://www.leg.state.fl.us
Florida Nurses Association (FNA). (2012). Retrieved from http://www.floridanurse.org
Hamilton PM. (1996). Realities of contemporary nursing (2nd ed.). Menlo Park, CA: Addison-Wesley Nursing.
Intervention Project for Nurses (IPN). (2014a). Retrieved from http://www.ipnfl.org
Intervention Project for Nurses (IPN). (2014b). IPN history. Retrieved from http://www.ipnfl.org
Joint Commission on Accreditation of Healthcare Organizations. (2011). Hospital accreditation standards. Oakbrook Terrace, IL: JCAHO. Retrieved from http://www.jointcommission.org
National Council of State Boards of Nursing (NCSBN). (2014). Nurse practice act, rules, and regulations. Retrieved from https://www.ncsbn.org
National Council of State Boards of Nursing (NCSBN). (n.d.). State and territorial boards of nursing: what every nurse needs to know. Retrieved from https://www.ncsbn.org
Raths LE, Harmin M, Simons SB. (1979). Values and teaching (2nd ed.). Columbus, OH: Merrill.
Rawls J. (1999). A theory of justice (rev. ed.). Cambridge, MA: Belknap Press.