Cyclic staff shortages create a market niche for the interim or long-term use of contracted personnel. Thus, nurses working in institutions that use contracted nurses as well as nurses whose employers are contracted agencies must be aware of their own accountability for their actions and practice in addition to their accountability to their employers, patients, and colleagues. The Institute of Medicine (IOM) report identified the need for all health care organizations to have in place mechanisms to achieve “flexible” staffing in instances when the patient census,
acuity, or both demand staffing at a higher level than anticipated. The IOM recommends using internal nursing “float pools” composed of nurses employed by the health care organization. Although using floating nurses may still result in nurses being assigned to patient care units with which they are less familiar, using an organization’s own float pool of employed nurses at least assures that these nurses have received the same orientation and in-house training as other nursing staff permanently assigned to specific nursing units. Float pools would also assure that, even if the floating nurses are not familiar with policies and procedures unique to individual patient care units within the organization, the nurses would be familiar with organization-wide policies and practices pertaining to patient safety, such as an organization’s error reporting system, decision support systems, and information technologies (Page, 2008).

A private duty nurse, who works under the direction, supervision, and control of a hospital and private physician/LIP, is subject to the rules and regulations of the hospital concerning all matters relating to nursing care. The institution’s joint policy statement may note that the private duty nurse who has complied with the criteria applicable to the administration of IV therapy may give an IV infusion.

Nationwide, temporary staffing agencies provide valuable assistance during shortages of licensed professional personnel. When given responsibility for the administration of intravascular therapies, agency personnel must be oriented to the health care facility’s policies and procedures and the functions performed by specialized department personnel. When the facility must use agency staff, every effort should be made to ensure patient safety, public protection, and viability of the IV therapy program.

Because of downsizing, restructuring, and nursing shortages in many areas of the country, various aspects of IV therapy may be performed by allied health personnel other than by registered nurses (RNs), such as licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and patient care technicians (PCTs). When performing IV care, LPNs or LVNs must have the necessary preparation and experience. In addition, they must be authorized by their employer and by the state in which they work before they perform any procedures. LPNs and LVNs are governed by the Nurse Practice Act in their state and are accountable for any procedure they accept and perform. PCTs, depending on their training and place of employment, may be trained to set up the equipment to start an IV or to monitor the IV while it is in place.

Nursing today requires a strong knowledge base and good observation skills. The act of observation is the legal and professional responsibility of the nurse. Frequent observation is imperative for the early detection and prevention of complications. Undetected complications that are allowed to increase in severity because of failure to observe the patient constitute an act of negligence on the part of the nurse.

Nurse-patient relationships play a significant role in influencing patients to initiate legal liability against nurses. Nurses performing infusion therapy must be particularly aware of and attentive to the emotional needs of their patients, particularly when patients experience pain and apprehension during such procedures as catheter insertion. Clearly, specialists must foster appropriate interpersonal relationships. Nurses who are impersonal, aloof, and so busy with the technical process of starting an IV infusion that they have no time for establishing kindly relationships are the suit-prone nurses whose personalities may initiate resentment and later malpractice suits.

Patients most likely to sue may be resentful, frequently hostile, uncooperative, and dissatisfied with the level of nursing care. By demonstrating respect, care, and concern for all patients, as well as rendering skilled, efficient nursing care, nurses may avoid malpractice claims.

Policies and procedures should be detailed, and all nurses practicing infusion therapy should be required to know them and review them periodically. Policies and procedures should follow national guidelines established by the Centers for Disease Control and Prevention (CDC)
and Standards of Practice established by the Infusion Nurses Society (INS). These guidelines provide a model for IV nurses and foster optimal care for the patient receiving IV therapy.

Documentation is essential as a legal record of care provided a communication tool for other health care professionals and a determinant of eligibility for reimbursement. Detailed, accurate, adequate documentation prevents reinvention of the wheel (or duplication of effort and services) by saving time, ensures that the patient masters skill sets, and protects the health care provider or the institution. Tools used to document care include nursing care plans, flow sheets, progress notes, periodic updates developed by home care providers, and discharge summaries (Rankin & Stallings, 1996).

Electronic medical records (EMR) have facilitated the process. A commercially available program involves an innovative technology that combines the safety features of an automatically programmed infusion pump with software that provides clinical visibility to realtime infusion data. The nurse validates the information, and the system begins infusing the medication to the patient as prescribed. The clinician can view the trends in real-time and in conjunction with the patient’s physiologic and hemodynamic data. http://www.cerner.com/solutions/Client_Stories/Wellspan_Health/

Documentation should include the intervention performed, the patient’s response to the intervention, and the subsequent outcomes. Sentinel or adverse events should also be documented consistent with institutional policy. By providing an accurate record of the care delivered and by structuring that care on evidence-based nursing practice and published standards, the nurse who is responsible for providing IV care ensures safe practice. The quality of infusion therapy is evaluated by the quality of the nursing documentation.

Accurate and complete documentation is considered a professional standard of nursing practice. Documentation that is incomplete or not consistent with organizational policy, state regulations, or state boards of nursing can be used to support an allegation of negligent care.

Credentialing of IV nurses nationwide began with the first certification examination in 1985. The credentialing process consists of three components: licensure, accreditation, and certification.

Licensure represents the entry into practice level afforded to all professional nurses who successfully complete the RN examination.

Accreditation establishes that a program or service meets established guidelines. Accreditation is offered to facilities, agencies, and other health care providers by such groups as TJC, which is an accrediting body that evaluates (rates) the programs of hospitals and home care agencies.

Certification is the highest level attainable by the professional IV nurse. It is the process by which society attests to the professional and clinical competence of the person who successfully completes the process.

Defining and evaluating competency in nursing is part of the yearly assessment of professionals in all clinical settings. The IV nurse’s competence in performing peripheral IV therapy should be assessed periodically. Of course, the competent IV nursing professional should be able to perform the procedure using aseptic technique. The health care environment is changing drastically to demand quality through efficiency and effectiveness in all aspects of patient care. Competency is required to attain quality and to provide the patient with optimal outcomes. Proof of infusion competency is crucial to ensure excellence in infusion care for all patients (Weinstein, 2000).

Nurse educators are challenged to implement teaching strategies that promote learners’ clinical competency and critical thinking skills. Additionally, these educators are asked to base their curriculum decisions, teaching practices, and evaluation methods on current research findings. Simulation offers a unique mode for experiential learning and evaluation, but the appropriate use of the spectrum of simulation typology requires strategic planning. Although simulation provides educators with new educational opportunities, the potential use of simulation in competency testing cannot be achieved until educators and researchers acquire the knowledge and skills needed to use this education strategy, develop realistic case scenarios, and design and validate standardized and reliable testing methods (Decker, Sportsman, Puetz & Billings, 2008). Simulation laboratories in clinical environments are helpful in documenting competencies in infusion nursing.

Health Insurance Portability and Accountability Act regulations have impacted confidentiality in all clinical settings. Confidentiality of patient information consists of three related components: privacy, confidentiality, and security (Conner, 1999). With current advances in communication, such as electronic mail (e-mail) and other communication systems, including fax machines, cellular or cordless telephones, phone, tablet and computer applications, answering machines, and voice mail, nurses need to be aware and vigilant in preventing the misdirection, printing, interception, rerouting, or reading of information by unintended recipients.

Technology alone cannot ensure the legal and ethical use of e-mail and other communications in the health care environment. The e-mail message, for example, accurately documents communication and, as such, is part of the medical record and a legal document.

Expert security sources recommend the use of multilevel, individual passwords for all e-mail users, as opposed to generic group sign-ons and systems that require a single pass code (Dorodny, 1998). Monitored audit trails and increased accountability of caregivers to their patients should be established (Conner, 1999). Health information has become a commodity over the Internet, and every precaution should be taken to maintain the confidentiality of electronic additions to the clinical record.

A standard must be carefully defined for the health care institution or the nurse to evaluate adequate performance. Tools useful in guiding this process include the following: