Advanced Practice Registered Nurses and License Protection Case Studies with Risk Management Strategies, Presented by NSO
A regulatory board complaint may be filed against an advanced practice registered nurse (APRN) or nurse practitioner (NP) by a patient, colleague, employer, and/or regulatory agency. Allegations in these matters may be directly related to an NP’s clinical responsibilities and professional services, although they may be of a nonclinical nature as well. For example, such complaints may assert unprofessional behavior, substance abuse, or billing fraud. Complaints are subsequently investigated by the State Board of Nursing (SBON), leading to outcomes ranging from no action against the NP to revocation of the NP’s license to practice. The following scenarios highlight the risks posed to an NP’s license apart from clinical practice issues.
Summary – Case Study #1: Criminal conviction related to the qualifications or duties of the profession
A police officer observed the insured NP back his vehicle into another vehicle as he was reversing out of a parking space, denting the rear bumper of the parked car. The officer then observed the NP pull his car away and begin to leave the scene. The officer stopped the NP and asked why he failed to stop after hitting the parked vehicle. The NP and the officer became involved in a verbal altercation. During this encounter, the NP proceeded to yell at the officer that he was an NP and could not wait for the owner of the parked vehicle to return to provide his insurance information due to the need to return to work. When the police officer tried to place the NP under arrest, the NP resisted, repeatedly jerking his arm away from the officer.
The NP was charged with resisting, delaying or obstructing a peace officer, which constitutes a misdemeanor. The NP pled no contest to this charge and was convicted. Upon renewal of his license, he reported this conviction to the SBON, as required in the state where the NP practiced.
The SBON opened an investigation into the NP’s conviction in order to determine whether his offense was substantially related to his ability to practice safely. The NP was able to produce letters of support and recommendation from colleagues attesting to his professionalism. The NP also worked with his attorney to formulate a letter expressing his regret regarding the incident, including other mitigating circumstances in this case.
Considering all of these factors, as well as his status as a licensee in good standing for more than 10 years, and the isolated nature of this event, the SBON decided against revoking or suspending the NP’s license. Instead, the SBON issued a public reprimand and required the NP to pay a $2,500 fine. Expenses paid to defend the insured NP in this matter totaled more than $1,600.
Summary – Case Study #2: Using improper title or credentials
In this matter, the insured was licensed to practice as a registered nurse and an advanced practice registered nurse (APRN), with the designation of a clinical nurse specialist (CNS). However, the insured began practicing as a certified nurse practitioner (CNP) from the time she received her certification from the American Nurse Credentialing Center (ANCC) as an adult-gerontology primary care nurse practitioner (AGPCNP). The insured used the initials “AGPCNP” on her CV and on the signatures of prescriptions she wrote for multiple patients. However, the insured failed to first secure a valid, current certificate of authority as a CNP from the SBON.
In the SBON proceeding, the insured stated that she believed that because she already held an advanced license with the SBON as an APRN, that any additional advanced certificates would automatically be encompassed under the original license since, by definition, these designations represent a type of APRN.
The SBON imposed a $1,000 fine and required the APRN to complete 16 continuing education hours within 6 months. Expenses incurred to defend the insured in this matter totaled almost $9,600.
Summary – Case Study #3: Failure to maintain professional boundaries with a patient
The NP worked in a primary care clinic that serviced mostly low-income patients. During a routine appointment, a patient, whom the NP had been treating for several years, advised that she was in the process of leaving an abusive relationship. However, she could not afford a new residence. The NP attempted to help connect the patient with local domestic violence resources, but none was able to offer immediate housing. The NP offered to permit the patient to stay in a guest apartment on her property on a short-term basis, until other housing could be secured.
The patient resided in the dwelling on the NP’s property for several months. The NP initially agreed to accept $200 per month for rent from the patient, but the patient’s hardship quickly prohibited her from paying rent. Eventually, she resided rent-free. After a colleague at the clinic learned that one of the clinic’s patients was living on the NP’s property, the colleague filed a report with the SBON.
The SBON received information that the insured NP offered housing to a patient for which there was a well-established, ongoing professional relationship. The SBON determined that the NP was subject to discipline for failure to establish or maintain professional boundaries with a patient.
In this matter, the SBON advised that they may take disciplinary action against the NP’s license, up to and including revocation of her license to practice. However, due to the NP’s cooperation with the SBON’s investigation into this matter, and because this was the NP’s first disciplinary matter in which the NP had been named over the course of her 20+ year nursing career, the SBON issued a formal reprimand. It further ordered the NP to complete continuing education courses on professional boundaries in nursing.
This matter took approximately 10 months to resolve, and the expenses incurred to defend the NP in this matter totaled more than $11,000.
Risk Management Comments and Recommendations
Below are some proactive concepts and behaviors to include in your practice to help mitigate the risk of SBON matters:
- Know the state-specific laws and requirements regarding the use of professional licensure titles and abbreviations. State laws and regulations define the criteria and licensure requirements for all Advanced Professional Registered Nurses (APRNs). APRNs include certified registered nurse anesthetists (CRNAs), certified nurse midwives (CNMs), clinical nurse specialists (CNSs) and certified nurse practitioners (CNPs) designations. Misrepresenting or misusing an advanced practice designation may subject an APRN to professional liability exposures.
- Avoid any activities that may jeopardize or raise questions concerning your ability to perform safe and competent practice (e.g. being impaired by drugs or alcohol while working, stealing from a patient and/or involved in any type of criminal conduct). According to the American Association of Nurse Practitioners (AANP) Scope of Practice for Nurse Practitioners, specifically the statement pertaining to accountability: “Each NP is accountable to patients, the nursing profession and the state board of nursing. NPs are expected to practice consistent with an ethical code of conduct, national certification, evidence-based principles and current practice standards.”
- Avoid any activities with patients that fall outside of accepted medical practices (e.g. agreeing to meet them at social events or communicating with them on social media outside of the parameters of a professional relationship). While not all professional boundary issues are equally serious, they tend to impair the objectivity and judgment of both parties, thereby potentially compromising the patient-provider relationship and distorting expectations.
- Practice within the parameters of your state nurse practice act, in compliance with organizational policies and procedures, and within the standard of care. If regulatory requirements and organizational scope of practice differ, comply with the most stringent of the applicable regulations or policy. If in doubt, contact your SBON or specialty professional nursing association for clarification.
- Maintain files that can be helpful with respect to your character. Retain copies of letters of recommendation, performance evaluations, thank-you letters from patients, awards, records of volunteer work and continuing education certificates.
- Finally, immediately contact your professional liability insurer if you:
- Become aware of a filed or potential professional liability matter against you.
- Receive a subpoena to testify in a deposition or trial.
- Have any reason to believe that there may be a potential threat to your license to practice nursing.
Disclaimer
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Suite 250, Fort Washington, PA 19034-3278. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.
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