Advancing your career – and minimizing risk

You just landed your first leadership role as a nurse manager. Or perhaps you’re shifting your career from bedside, hospital-based nursing to home care nursing because you’re ready for a new challenge. Congratulations! Advancing your career, whether by taking a leadership position or exploring a new specialty, can lead to enhanced job satisfaction and a bigger paycheck.


But career changes also can put you at greater legal risk as you take on more or new responsibilities. For example, as a preceptor you are legally responsible for making appropriate assignments for your preceptee. If a new nurse harms a patient who had needs too complex for the nurse’s level of expertise, you could be held liable.

By understanding the potential for liability and taking steps to protect yourself, such as notifying your insurance provider when you have a change in role or responsibilities to ensure your coverage is adequate, you can reduce the risk of legal action as you advance your career. 
 

Liability, role, and specialty

According to the 2020 CNA/NSO Nurse Professional Liability Exposure Claim Report: 4th Edition, the number and amount of claims vary by role and by specialty. For example, home care, which includes home health, hospice, and palliative care, topped the list of the most common closed claims by specialty at 20.7%, up from 12.4% in the 2015 report. It should be noted, however, that this doesn’t necessarily mean home care nurses are more likely to be sued; rather, the increase may reflect the overall trend of care shifting from hospital to home.

The report noted that the highest average total incurred amount (defined as the costs or financial obligations resulting from the resolution of a claim, divided by the total number of closed claims), was for obstetrics claims, likely because some of these cases can result in the need for the patient to receive extensive or even lifelong one-on-one nursing care. This was followed by postanesthesia care unit and behavioral health claims.

Whether you’re taking on a leadership role or changing specialties, the following strategies can help you to mitigate the risks of a claim.
 

Becoming a leader

The nurse leader role can be rewarding as you mentor others and advocate for quality patient care. In addition to formal roles such as charge nurse, nurse manager, and director of nursing, leaders also serve as educators and preceptors.

As you take on additional responsibilities, however, keep in mind that you have new legal risks because lawsuits have named leaders based on their actions related to duties such as hiring and educating staff and making patient care assignments. The CNA/NSO report found that the greatest average total incurred amount for nurses in leadership roles was for those in correctional health, followed by the postanesthesia care unit and aging services. In fact, 38.7% of closed claims related to leaders in aging services settings, while 32.3% were related to care delivered in the patient’s home.

As a new leader, be sure you understand the expectations for the role. Carefully review your job description (and the job descriptions for those reporting to you) and don’t be afraid to ask questions. Consider putting a plan in place to help you make a smooth transition (see New leader action plan).

Check your state’s nurse practice act and board of nursing position statements for any relevant information. A 2018 study by L’Ecuyer and colleagues found that some state boards of nursing had specific requirements related to preceptors and student nurses. An example of a position statement of interest to new leaders is the one on floating from the New York State Nurses Association, which states that employers are responsible for providing appropriate orientation and training of staff who float to other units.

Also be aware of competencies, both required and suggested. For example, local and state regulations may require certain competencies, while associations may suggest ones. For example, the American Nurses Association’s (ANA) Nursing: Scope and Standards of Practice, 4th Edition includes several leadership competencies. In addition, the American Organization for Nursing Leadership has developed suggested competencies in three areas: the science, the art, and the leader within. Competency in these three areas can help you avoid legal action. For instance, a human resource management competency under the science section is: “Match staff competency with patient acuity.” By doing so, you can reduce the risk of a claim that could occur. For example, you could be held responsible if harm results when you assign a nurse who is not competent in negative pressure wound therapy to a patient receiving it. Even recommended or suggested competencies can play a role in a lawsuit because they indicate what is accepted practice.

Finally, you’ll want to be aware of any local, state, and federal laws related to your role. Some states have nurse-patient ratios that you’ll need to consider when making assignments.
 

A change in specialty

Changing specialties can be an excellent way to rejuvenate your career, but specialty also can affect the number of claims and the amounts paid to close claims. In addition to obstetrics, other specialties with high average total incurred amounts are the postanesthesia care unit, behavioral health, correctional health, and critical care, according to the CNA/NSO report.

After home care, specialties with the highest percentage of closed claims were adult medical/surgical (18.5%), gerontology in an aging services facility (10.5%), emergency and urgent care (9.7%), obstetrics (6.2%), and adult critical care (5.9%).

As with a leadership role, you can take steps to lessen your legal risk. The first source to turn to is your state’s nurse practice act and any position statements related to your new specialty and scope of practice. For example, the Texas Board of Nursing’s position statement on nurses reinserting permanently placed feeding tubes states that nurses must complete a training course and follow various guidelines before performing this procedure. If you were a new home care nurse and reinserted the tube without meeting these requirements, you could be held liable if the patient developed a complication.

Also check with national nursing associations for resources. The ANA publishes books on the scope and standards of practice for a variety of specialties, such as cardiovascular nursing. Specialty organizations, like the Association of periOperative Nurses, also publish standards that you should review and adhere to. Failure to do so puts you at risk for legal action should patient harm occur. In addition, specialty associations are a source for competencies related to the role; meeting these competencies helps you deliver safe, effective care.  


New leader action plan
Rose Sherman, a leadership expert, recommends creating a 100-day plan to ease the transition from staff nurse to leader. The plan should include strategies related to six competency areas: personal mastery, interpersonal effectiveness, human resources (HR) management, financial management, systems thinking, and caring for self/staff/patients. Several of Sherman’s suggested strategies can help you avoid legal pitfalls. 

  • Review your position description and evaluation criteria. You need to know what is expected of you.
  • Review the position descriptions for each staff position and evaluation criteria. You need to know what you can expect from staff.
  • Meet 1:1 with each direct report. In additional to finding their strengths, this can help you identify competency and skill levels to consider when making assignments and planning education programs so staff can care for patients effectively.
  • Learn about the HR recruitment process to fill vacancies. Be sure you understand what you are legally able to ask during an interview. 
  • Determine the HR process for managing performance issues and challenges. You’ll want to follow these closely to reduce the risk of lawsuits by disgruntled employees.
  • Review the organizational chart. This will help you understand whom you should contact with questions and problems. 
 

A positive career move

Don’t let a positive career opportunity become a negative by failing to prepare yourself for your new role or not having adequate liability coverage. By taking a few steps (see Advancing your career checklist), you can ensure your career stays on track.
 

Advancing your career checklist
Use these strategies to help avoid possible legal problems related to a career change:

Ask for a mentor.
Be sure your orientation is sufficient.
Read your job description and policies and procedures.  
Review your state’s nurse practice act and any position statements related to your new role. 
Access standards from the ANA and specialty associations.
Review required and suggested competencies from local, state, and federal organizations and from national associations.
Conduct a self-assessment to determine what skills you have and what skills you need to develop. 
Ask for help as needed. 
Explore online resources such as websites for associations and boards of nursing. For example, board of nursing websites often have answers to commonly asked questions about scope of practice.
Notify your insurance provider of any change in role and responsibilities to ensure you have adequate coverage. 
Once you gain some experience, consider becoming certified. Studying for the certification test can help boost your expertise and your confidence. 

By Cynthia Saver, MS, RN, President, CLS Development, Columbia, Maryland.

RESOURCES
American Nurses Association. Nursing: Scope and Standards of Practice. 4th ed. Silver Spring, MD: American Nurses Association; 2021.
CNA, NSO. Nurse Professional Liability Exposure Claim Report: 4th Edition. 2020. www.nso.com/nurseclaimreport.
American Organization for Nursing Leadership. Nurse Manager Competencies. 2015. www.aonl.org/resources/nurse-leader-competencies.
L’Ecuyer KM, von der Lancken S, Mallow D, Meyer G, Hyde MJ. Review of state boards of nursing rules and regulations for nurse preceptors. J Nurs Educ. 2018;57(3):134-141. https://journals.healio.com/doi/10.3928/01484834-20180221-02
New York State Nurses Association. Position statement on floating.  2018. www.nysna.org/position-statement-floating.
Sherman RO. The Nuts and Bolts of Nursing Leadership: Your Toolkit for Success. 2021.
Texas State Board of Nursing. 15.23: Nurses engaging in reinsertion of permanently placed feeding tubes. Position Statement. www.bon.texas.gov/practice_bon_position_statements_content.asp#15.24.


Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information. Please note that Internet hyperlinks cited herein are active as of the date of publication but may be subject to change or discontinuation.
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Frequently Asked Questions

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What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 


The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 


How does a shared limit policy work?


A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.


We have a shared limit policy. Are employees covered if they practice outside our office?


The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.



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