Online Undergraduate Course

NURS 450 - RN to BSN Transition: Implications for Practice, Policy and the Profession

Module 6: Legal Considerations

Laws: Federal and State

Both federal and state laws influence nurses and their professional practice. Federal laws emanate from the federal government and have oversight by a federal agency. Federal laws pertain to all individuals within the U.S. and the U. S. territories. State laws are enacted by an individual state and pertain to all individuals living or doing business in that state. An easy example of a state law is the requirement to have a driver’s license and to follow traffic laws such as the posted speed limit. Each RN must take accountability for knowing the law and understanding how it relates to patient care and nursing practice. Below are several examples of federal and state laws that influence nursing practice.

Federal Statutes (Laws)

Federal statutes that nurses should be familiar with and have a clear understanding of are discussed below. This list is not comprehensive, but it includes examples of federal law that directly affect nursing practice. Many federal laws are relevant to specific health care settings (i.e., Emergency Departments). When nurses are knowledgeable about the federal laws applicable to their area of practice, they will be able effectively advocate for patients in that setting.

Affordable Care Act (ACA). In 2010, the Obama administration passed the Affordable Care Act—the most sweeping healthcare insurance legislation to affect the public in several decades. The act requires most U.S. citizens to apply for health insurance coverage, levying a penalty for individuals who fail to secure insurance but making exceptions for a few protected groups. During the Trump administration the penalty was changed to 0$.

Under the law, enterprises that employ more than 200 workers must provide health insurance coverage. The act also established the American Health Benefits Exchange, where citizens can review and compare insurance plans. The ACA offers health care professionals the opportunity to participate in shaping the delivery of patient services. The medical field can benefit from input that helps deliver better services to the growing patient population while reducing care expenses.

The Affordable Care Act (ACA) continues to be examined and possibly overturned. The U.S. Supreme Court upheld the ACA for the third time. On June 17, 2021 the United States Supreme Court (SCOTUS), in a 7-2 decision, rejected a legal challenge to the ACA initiated by Texas and several other states. SCOTUS ruled that the states lacked standing, or the legal right to sue. This case marks the third time that SCOTUS has upheld the law.

The initial landmark legislation, passed in 2010, included an individual “mandate,” or tax penalty on individuals who did not seek insurance coverage. Two years later in its first major ruling on the law, SCOTUS affirmed that the mandate is constitutional because the U.S. Congress has the authority to levy taxes. In 2017, Congress lowered the tax penalty to $0 while leaving in place language about the mandate, leading to this most recent case. Texas and other states alleged the ACA was not constitutional because the mandate was no longer a tax penalty and therefore not within Congress’s authority. Rather than rule on the merits of the case, SCOTUS decided that the states lacked legal standing, because they could not demonstrate how they have been harmed because of the tax penalty being effectively eliminated. The result of that decision is that ACA will remain in place, and any future challenges or reforms to it are likely to be legislative rather than legal. Interesting… right?

Americans with Disabilities Act (ADA) of 1990: The intent of this law is to end discrimination against qualified person’s disabilities by removing barriers that prevent them from enjoying the same opportunities available to persons without disabilities. This can be done through:

  • Reasonable Modifications of Policies, Practices, and Procedures. Adjusting policies, practices, and procedures, if needed, to provide goods, services, facilities, privileges, advantages, or accommodations.
    • A health care organization/facility has barriers such as steps at their entrance or examination rooms that are too small to accommodate a person who uses a wheelchair. To meet their access requirements, the provider must develop a plan to remove those barriers to make the site accessible unless it is technically infeasible. Or, a doctors’ office is in an existing building with 4 small exam rooms. Making all of the exam rooms accessible may not be readily achievable because load-bearing walls cannot be removed or the cost of the full project may be too high. Instead, the doctor could make two of the rooms accessible and ensure they only schedule two patients who would benefit from an accessible room at the same time.
  • Effective Communication. Making communication, in all forms, easily understood.
    • For a person who is Deaf and uses sign language, providing a qualified sign language interpreter for a scheduled or non-emergency appointment. Or, for a person with low vision, providing a qualified reader for written information and providing post- op discharge instructions and medication management in large print.
  • Accessible Facilities. Ensuring physical accessibility.
    • Allowing a service dog that has been trained to alert their handler with a seizure disorder at the onset of a seizure to be present in an exam room. Or, allowing a companion to assist a person with a mobility disability when positioning the patient for a radiology scan (ADA National Network, 2020).

If interested, read more about ADA on

Emergency Medical Treatment and Active Labor Law Act (EMTALA): This federal statute was enacted in 1986 to prohibit the refusal of care for indigent and uninsured patients seeking medical assistance in the emergency department. The law also prohibits the transfer of unstable patients (including women in labor) from one facility to another (Centers for Medicare and Medicaid Services, 2012). Referred to as the "anti-dumping" law, it was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer. As a result, local and state governments began to abdicate responsibility for charity care, shifting this public responsibility to all hospitals.

If interested, read more about EMTALA at

Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law No. 104- 191): The intent of this law is to ensure confidentiality of the patient's medical records. The introduction of electronic medical records has provided additional impetus for introduction of this legislation. The statute sets guidelines for maintaining the privacy of health data. Legitimate concerns regarding the uses of and release of medical information, particularly to private entities such as insurance companies, led to the passage of this law. It provides explicit guidelines for nurses who are in a position to release health information. To maintain confidentiality of the medical record and privacy of patients' health data, all nurses must have a basic understanding of the new rules and regulations that went into effect in 2001.

If interested, read more about HIPAA at

Patient Self-Determination Act of 1990 and Omnibus Budget Reconciliation Act of 1990: This federal statute is a Medicare/Medicaid amendment intended to support individuals in expressing their preferences about medical treatment and making decisions about end-of-life care. The law requires that all federally funded hospitals inform adult patients about their rights to make treatment choices and to ask patients whether they have a prepared living will or have a executed a durable power of attorney for health care.

If interested, read more about the Patient Self-Determination Act of 1990 at

Patient Safety and Quality Improvement Act (PSQIA) of 2005: The Patient Safety and Quality Improvement Act (PSQIA) protects health care workers who report unsafe conditions. Legislators created the law to encourage the reporting of medical errors, while maintaining patients’ confidentially rights. To ensure patient privacy, the Department of Health and Human Services (DHHS) levies fines for confidentially breaches. The law also authorizes the Agency for Healthcare Research and Quality (AHRQ) to publish a list of patient safety organizations (PSOs) that record and analyze patient safety data. The Office for Civil Rights (OCR) enforces the law among national health care facilities.

If interested, read more about PSQIA at

Mandatory Reporting

Nurses are mandatory reporters. Mandatory reporters does not mean anonymous reporting. Nurses need to be aware of the federal and state reporting requirements.

 The key Federal legislation addressing child abuse and neglect is the Child Abuse Prevention and Treatment Act (CAPTA), originally enacted on January 31, 1974 (P.L. 93-247). This act has been amended several times and was last reauthorized on December 20, 2010, by the CAPTA Reauthorization Act of 2010 (P.L. 111-320). It was amended in 2015, 2016, and 2018, and most recently, certain provisions of the act were amended on January 7, 2019, by the Victims of Child Abuse Act Reauthorization Act of 2018 (P.L. 115-424).

CAPTA requires each state to have provisions or procedures for requiring certain individuals to report known or suspected instances of child abuse and neglect. All states and the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands must identify in statute the professionals and other persons who are required to report instances of suspected child maltreatment. These statutes also address reporting by other persons, the responsibilities of institutions in making reports, standards for making a report, and confidentiality of the reporter’s identity. An individual may notify the local department or appropriate law enforcement agency if the individual has reason to believe that a parent, guardian, or caregiver of a child allows the child to reside with or be in the regular presence of an individual, who is registered as a child sex offender and, based on additional information, poses a substantial risk of sexual abuse to the child.

CAPTA was further amended by the Justice for Victims of Trafficking Act of 2015 (P.L. 114-22, 5/29/2015). Effective May 2017, States are required, as part of their CAPTA State plans, to have in place the following provisions and procedures: (1) a requirement to identify and assess all reports involving children known or suspected to be victims of sex trafficking and (2) to train child protective services workers about identifying, assessing, and providing comprehensive services for children who are sex trafficking victims, including efforts to coordinate with State law enforcement, juvenile justice, and social services agencies, such as runaway and homeless youth shelters. It also expanded the Federal definition of “child abuse and neglect” and “sexual abuse” to include a child who is identified as a victim of sex trafficking or severe forms of trafficking in persons.

If interested, read more about CAPTA at

For those practicing in the state of Maryland, consider reading Maryland Mandatory Reporters of Child Abuse and Neglect rules at

Enacted as part of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, the Elder Justice Act (EJA) was the first piece of federal legislation passed to authorize a specific source of federal funds to address elder abuse, neglect and exploitation. States requires individuals employed in a long-term care facility to report to the appropriate state agency.

More importantly, EJA protects older adults, generally 65 years and older, from physical abuse, neglect, financial exploitation, psychological abuse, sexual abuse, and abandonment. If an individual reasonably believes a crime occurred, and those events resulted in serious bodily injury to an elderly resident, that individual must report the suspicion to the Department of Health and Human Services (DHHS) state survey agency and to one local law enforcement agency within two hours after they developed the suspicion. If the suspicion is based on events that did not lead to serious bodily injury, the individual must report the suspicion within 24 hours.

What is elder abuse? Elder abuse are behaviors considered to be “intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (National Center for Injury Prevention and Control, Division of Violence Prevention, 2021). Elder abuse and neglect may occur in domestic or institutional settings, as described below:

  • Domestic elder abuse generally refers to any of the following types of mistreatment that are committed by someone with whom the elder has a special relationship (e.g., a spouse, sibling, child, friend, or caregiver).
  • Institutional elder abuse generally refers to any of the following types of mistreatment occurring in residential facilities (e.g., a nursing facility, assisted living facility, group home, board and care facility, or foster home) and is usually perpetrated by someone with a legal or contractual obligation to provide some element of care or protection.

If interested, read more about elder abuse at

State Statues (Laws)

In addition to federal laws, state laws that delineate the conduct of licensed nurses and define behaviors of all health care professionals in promoting public health and welfare govern nursing practice. The key state law each nurse should know is the state Nurse Practice Act (NPA).

Each state working with the Board of Nursing defines the term registered nurse, professional nursing functions, standards of competent performance, behaviors that represent misconduct or prohibited practice, grounds for disciplinary action, as well as the fines and penalties the licensing board may levy when the Nursing Practice Act is violated. The aim of regulating practice in this manner is to protect the public and make the individual nurse accountable for his or her actions. State legislatures authorize the nurses' licensing board to promulgate administrative rules and regulations necessary to implement the NPA. Once these administrative rules and regulations are formally adopted, they have the same force and effect as any other law (Nurse's Legal Handbook, 2000).

Although nursing practice acts vary from state to state, they usually contain the following information:

  • Definition of the term registered nurse (RN)
  • Description of professional nursing functions
  • Standards of competent performance
  • Behaviors that represent misconduct or prohibited practices
  • Grounds for disciplinary action
  • Fines and penalties the licensing board may levy when the Nursing Practice Act is violated (e.g., being impaired by drugs or alcohol while working; stealing from a patient/client, including medications; providing treatment or care that should be provided only by a physician or APRN; falsifying records)

Surprisingly, many nurses are not even aware that the NPA is a law and they may unknowingly violate aspects of this statute. This is an unfortunate lapse because deviations from the NPA may lead to malpractice and/or having licensure revoked or suspended. Where can you finds the Nurse Practice Act for those RN licensed in the state of Maryland? Maryland laws and regulations can also be found on the internet by searching for Annotated Code of Maryland (Health Occupations Article, Title 8. Nurses) and Code of Maryland Regulations (COMAR). The relevant regulations are found under COMAR Title 10, Subtitle 27.

What does encumbered mean? An encumbered nursing license is one that has one or more restrictions imposed on it, which may prevent you from working in certain capacities, or from working at all. An encumbered nursing license is one that has been:

1. Revoked,
2. Suspended, or
3. Otherwise restricted.

In addition to the NPA, all fifty states and District of Columbia have created laws that mandate reporting of specific health problems and the suspected or confirmed abuse of vulnerable individuals in society, such as the elderly or children. Nurses often are explicitly named within the context of these statutes as one of the groups designated health professionals who must report the specified problems under penalty of fine or imprisonment. As with laws regarding the mandatory reporting of abuse and mistreatment of vulnerable populations, the number and types of mandatory reportable diseases are dependent on the laws of the governing state, though many states adopt the recommended list published by the Centers for Disease Control (CDC).

The following are reportable in all states plus the District of Columbia:

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