Posted: July 17th, 2022

Nursing Leadership Essay

,. ,, < F.A.DAVIS s

ESSENTIALS OF

Nursing Leadership & Management

SEVENTH EDITION

Sally A. Weiss , EdD, APRN, FNP-C, CNE, ANEF

Professor, Lead Faculty Graduate Program Herzing University

Menominee Falls, Wisconsin

Ruth M. Tappen , EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor

Florida Atlantic University College of Nursing Boca Raton, Florida

Karen A. Grimley , PhD, MBA, RN, NEA-BC, FACHE

Chief Nursing Executive, UCLA Health Vice Dean, UCLA School of Nursing

Los Angeles, California

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2019 by F. A. Davis Company

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Names: Weiss, Sally A., 1950- author. | Tappen, Ruth M., author. | Grimley, Karen A., author. Title: Essentials of nursing leadership & management / Sally A. Weiss, Ruth M. Tappen, Karen A.

Grimley. Description: Seventh edition. | Philadelphia : F. A. Davis Company, [2019] | Includes bibliographical

references and index. Identifi ers: LCCN 2019000397 (print) | LCCN 2019001079 (ebook) | ISBN 9780803699045 | ISBN

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v

To my granddaughter, Sydni, and my grandsons, Logan and Ian. Th eir curiosity and hunger for learning remind me how nurturing our novice nurses helps them in their quest to seek

new knowledge and continue their professional growth. —S ALLY A. W EISS

To students, colleagues, family, and friends, who have taught me so much about leadership.

—R UTH M. T APPEN

To my kids, Kristina, Kathleen, Meagan, and Ian, for their love and understanding during this lifelong pursuit of learning.

To my dad for teaching me that the only limits we face are the ones we create and to my mom for instilling the value of a good

education. —K AREN A. G RIMLEY

Dedication

vii

We are pleased to bring our readers this seventh edition of Essentials of Nursing Leadership & Management. Th is new edition has been updated to refl ect the dynamic health-care environment, new safety and quality initiatives, and changes in the nursing practice environment. As in our previ- ous editions, the content, examples, and diagrams were designed with the goal of Helping the new graduate to make the transition to professional nursing practice.

Our readers may have noticed that we have added a new author to our team: Dr. Karen A. Grimley, Chief Nurse Executive at UCLA Health Center and Vice Dean of the School of Nursing at UCLA. We are delighted to have her join us, bringing a fresh perspective to this new edition.

Th e seventh edition of Essentials of Nursing Leadership & Management focuses on essential lead- ership and management skills and the knowledge needed by the staff nurse as a key member of the interprofessional health-care team and manager of patient care. Issues related to setting priorities, delegation, quality improvement, legal parameters of nursing practice, and ethical issues were also updated for this edition.

Th is edition discusses current quality and safety issues and the high demands placed on nurses in the current health-care environment. In addition, we continue to bring you comprehensive, practical information on developing a nursing career and addressing the many workplace issues that may arise in practice.

Th is new edition of Essentials of Nursing Leadership & Management will provide a strong foun- dation for the beginning nurse leader. We want to thank all of the people at F. A. Davis for their continued support and Helpance in bringing this edition to fruition. We also want to thank our contributors, reviewers, colleagues, and students for their enthusiastic support. Th ank you all.

—S ALLY A. W EISS

R UTH M. T APPEN

K AREN A. G RIMLEY

Preface

ix

CANDACE JONES, BSN, MSN, RN Professor of Nursing

Greenville Technical College Greenville, South Carolina

SUSAN MUDD, MSN, RN, CNE Coordinator, Associate Degree Nursing Program

Elizabethtown Community & Technical College

Elizabethtown, Kentucky

DONNA WADE, RN, MSN Professor of Nursing

Mott Community College Flint, Michigan

JENNA L. BOOTHE, DNP, APRN, FNP-C Helpant Professor

Hazard Community and Technical College Hazard, Kentucky

LYNETTE DEBELLIS, MS, RN Chairperson and Helpant Professor of Nursing

Westchester Community College Valhalla, New York

SONYA C. FRANKLIN, RN, EdD/CI, MHA, MSN, BSN, AS, ADN

Associate Professor of Nursing

Cleveland State Community College Cleveland, Tennessee

Reviewers

xi

unit 1 Professionalism 1 chapter 1 Characteristics of a Profession 3 chapter 2 Professional Ethics and Values 13 chapter 3 Nursing Practice and the Law 35

unit 2 Leading and Managing 55 chapter 4 Leadership and Followership 57 chapter 5 Th e Nurse as Manager of Care 71 chapter 6 Delegation and Prioritization of Client Care Staffi ng 81 chapter 7 Communicating With Others and Working

With the Interprofessional Team 99 chapter 8 Resolving Problems and Confl icts 117

unit 3 Health-Care Organizations 131 chapter 9 Organizations, Power, and Professional

Empowerment 133 chapter 10 Organizations, People, and Change 149

chapter 11 Quality and Safety 163 chapter 12 Maintaining a Safe Work Environment 181 chapter 13 Promoting a Healthy Work Environment 197

unit 4 Your Nursing Career 213 chapter 14 Launching Your Career 215 chapter 15 Advancing Your Career 235

Table of Contents

xii Table of Contents

unit 5 Looking to the Future 249 chapter 16 What the Future Holds 251

Bibliography 263

Appendices appendix 1 Standards Published by the American Nurses Association 285 appendix 2 Guidelines for the Registered Nurse in Giving, Accepting,

or Rejecting a Work Assignment 287 appendix 3 National Council of State Boards of Nursing Guidelines

for Using Social Media Appropriately 293 appendix 4 Answers to NCLEX® Review Questions 295 Index 321

chapter 1 Characteristics of a Profession

chapter 2 Professional Ethics and Values

chapter 3 Nursing Practice and the Law

unit 1 Professionalism

3

OUTLINE Introduction

Professionalism Defi nition of a Profession Professional Behaviors

Evolution of Nursing as a Profession Nursing Defi ned

The National Council Licensure Examination Licensure Licensure by Endorsement Qualifi cations for Licensure Licensure by Examination

NCLEX-RN ®

Political Infl uences and the Advance of Nursing Professionals

Nursing and Health-Care Reform

Nursing Today

The Future of Professional Nursing

Conclusion

OBJECTIVES After reading this chapter, the student should be able to: ■ Explain the qualities associated with a profession

■ Diff erentiate between a job, a vocation, and a profession

■ Discuss professional behaviors

■ Determine the characteristics associated with nursing as a profession

■ Explain licensure and certifi cation

■ Summarize the relationship between social change and the advancement of nursing as a profession

■ Discuss some of the issues faced by the nursing profession

■ Explain current changes impacting nursing ’ s future

chapter 1 Characteristics of a Profession

4 unit 1 ■ Professionalism

Introduction

It is often said that you do not know where you are going until you know where you have been. More than 40 years ago, Beletz ( 1974 ) wrote that most people thought of nurses in gender- linked, task-oriented terms: “a female who per- forms unpleasant technical jobs and functions as an Helpant to the physician” (p. 432). Interest- ingly, physicians in the 1800s viewed nursing as a complement to medicine. According to War- rington ( 1839 ), “. . . the prescriptions of the best physician are useless unless they be timely and properly administered and attended to by the nurse” (p. iv).

In its earliest years, most nursing care occurred at home. Even in 1791 when the fi rst hospital opened in Philadelphia, nurses continued to care for patients in their own home settings. It took almost another century before nursing moved into hospitals. Th ese institutions, mostly dominated by male physicians, promoted the idea that nurses acted as the “handmaidens” to the better-educated, more capable men in the medical fi eld.

Th e level of care diff ered greatly in these early health-care institutions. Th ose operated by the religious nursing orders gave high-quality care to patients. In others, care varied greatly from good to almost none at all. Although the image of nurses and nursing has advanced considerably since then, some still think of nurses as helpers who carry out the physician ’ s orders.

It comes as no surprise that nursing and health care have converged and reached a crossing point. Nurses face a new age for human experience; the very foundations of health practices and thera- peutic interventions continue to be dramatically altered by signifi cantly transformed scientifi c, technological, cultural, political, and social realities ( Porter-O’Grady , 2003 ). Th e global environment needs nurses more than ever to meet the health- care needs of all.

Nursing sees itself as a profession rather than a job or vocation and continues with this quest for its place among the health-care disciplines. However, what defi nes a profession? What behaviors are expected from the members of the profession? Chapter 1 discusses nursing as a profession with its own identity and place within this new and ever-changing health-care system.

Professionalism

Defi nition of a Profession A vocation or calling defi nes “meaningful work” depending on an individual ’ s point of view ( Dik & Duff y, 2009 ). Nursing started as a vocation or “calling.” Until Nightingale, most nursing occurred through religious orders. To care for the ill and infi rmed was a duty ( Kalisch & Kalisch, 2004 ). In early years, despite the education required, nursing was considered a job or vocation ( Cardillo, 2013 ).

Providing a defi nition for a “profession” or “pro- fessional” is not as easy as it appears. Th e term is used all the time; however, what characteristics defi ne a professional? According to Saks ( 2012 ), several theoretical approaches have been applied to creating a defi nition of a profession, the older of these looking only at knowledge and expertise, whereas later ones include a code of ethics, prac- tice standards, licensure, and certifi cation, as well as expected behaviors ( Post, 2014 ).

Nurses engage in specialized education and training confi rmed by successfully passing the National Council Licensure Examination (NCLEX®) and receiving a license to practice in each state. Nurses follow a code of ethics and recognized practice standards and a body of con- tinuous research that forms and directs our practice. Nurses function autonomously within the desig- nated scope of practice, formulating and delivering a plan of care for clients, applying judgments, and utilizing critical thinking skills in decision making ( Cardillo, 2013 ).

Professional Behaviors According to Post ( 2014 ), professional characteris- tics or behaviors include:

■ Consideration ■ Empathy ■ Respect ■ Ethical and moral values ■ Accountability ■ Commitment to lifelong learning ■ Honesty

Professionalism denotes a commitment to carry out specialized responsibilities and observe ethical principles while remaining responsive to diverse recipients ( Al-Rubaish, 2010 ). Communicating

chapter 1 ■ Characteristics of a Profession 5

eff ectively and courteously within the work envi- ronment is expected professional behavior. State boards of nursing through the nurse practice acts elaborate expected behaviors in a registered nurse ’ s professional practice and personal life (National Council of State Boards of Nursing [ NCSBN], 2012, 2016 ). Nurses may lose their licenses for a variety of actions deemed unprofessional or illegal. For example, inappropriate use of social media, posting emotionally charged statements in blogs or forums, driving without a license, and committing felonies outside of professional practice may be cause for suspending or revoking a nursing license.

Commitment to others remains central to a profession. In nursing, this entails commitment to colleagues, lifelong learning, and accountability for one ’ s actions. Professionalism in the workplace means coming to work when scheduled and on time. Coming to work late shows disrespect to your peers and colleagues. It also indicates to your super- visor that this position is not important to you.

Always portray a positive attitude. Although everyone experiences a bad day, projecting personal feelings and issues onto others aff ects the work environment. Many agencies and institutions have dress codes. Dress appropriately per the employ- er ’ s expectations. Wearing heavy makeup, colognes, or inappropriate hairstyles demonstrates a lack of professionalism. Finally, always speak profession- ally to everyone in the work environment. A good rule to follow should be, “If you wouldn ’ t say it in front of your grandmother, do not say it in the workplace” ( McKay, 2017 ).

Work politics often create an unfavorable envi- ronment. Stay away from gossip or engaging in negative comments about others in the workplace. Change the topic or indicate a lack of interest in this type of verbal exchange. Negativity is conta- gious and aff ects workplace morale. Professionals maintain a positive attitude in the work environ- ment. If the environment aff ects this attitude, it is time to look for another position ( McKay, 2017 ).

Lastly, professional behavior entails honesty and accountability. If a day off is needed, take a personal or vacation day; save sick days for illness. Own up to errors. In nursing, an error may result in injury or death. Th e health-care environment should promote a culture of safety, not one of pun- ishment for errors. Th is is discussed more in later chapters.

Evolution of Nursing as a Profession

Nursing Defi ned Th e changes that have occurred in nursing are refl ected in the defi nitions of nursing that have developed through time. In 1859, Florence Night- ingale defi ned the goal of nursing as putting the client “in the best possible condition for nature to act upon him” ( Nightingale, 1992/1859 , p. 79). In 1966, Virginia Henderson focused her defi nition on the uniqueness of nursing:

Th e unique function of the nurse is to Help the individual, sick or well, in the performance of those

activities contributing to health or its recovery (or

to peaceful death) that he would perform unaided

if he had the necessary strength, will or knowledge.

And to do this in such a way as to help him gain

independence as rapidly as possible. ( Henderson, 1966 , p. 21)

Martha Rogers defi ned nursing practice as “the process by which this body of knowledge, nursing science, is used for the purpose of Helping human beings to achieve maximum health within the potential of each person” ( Rogers, 1988 , p. 100). Rogers emphasized that nursing is concerned with all people, only some of whom are ill.

In the modern nursing era, nurses are viewed as collaborative members of the health-care team. Nursing has emerged as a strong fi eld of its own in which nurses have a wide range of obligations, responsibilities, and accountability. Recent polls show that nurses are considered the most trusted group of professionals because of their knowl- edge, expertise, and ability to care for diverse populations.

Nightingale ’ s concepts of nursing care became the basis of modern theory development, and in today ’ s language, she used evidence-based prac- tice to promote nursing. Her 1859 book Notes on Nursing: What It Is and What It Is Not laid the foun- dation for modern nursing education and practice. Many nursing theorists have used Nightingale ’ s thoughts as a basis for constructing their view of nursing.

Nightingale believed that schools of nursing must be independent institutions and that women who were selected to attend the schools should be

6 unit 1 ■ Professionalism

from the higher levels of society. Many of Night- ingale ’ s beliefs about nursing education are still applicable, particularly those involved with the progress of students, the use of diaries kept by students, and the need for integrating theory into clinical practice ( Roberts, 1937 ).

Th e Nightingale school served as a model for nursing education. Its graduates were sought worldwide. Many of them established schools and became matrons (superintendents) in hospitals in other parts of England, the British Common- wealth, and the United States. However, very few schools were able to remain fi nancially indepen- dent of the hospitals and thus lost much of their autonomy. Th is was in contradiction to Nightin- gale ’ s philosophy that the training schools were educational institutions, not part of any service agency.

The National Council Licensure Examination

Professions require advanced education and an advanced area of knowledge and training. Many are regulated in some way and have a licensure or certifi cation requirement to enter practice. Th is holds true for teachers, attorneys, physicians, and pilots, just to name a few. Th e purpose of a profes- sional license is to ensure public safety, by setting a level of standard that indicates an individual has acquired the necessary knowledge and skills to enter into the profession.

Licensure Licensure for nurses is defi ned by the NCSBN as the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activities are complex, require specialized knowledge and skill, and involve independent decision making ( NCSBN, 2012 ). Government agencies grant licenses allowing an individual to engage in a professional practice and use a specifi c title. State boards of nursing issue nursing licenses. Th is limits practice to a specifi c jurisdiction. However, as the NCLEX® is a nation- ally recognized examination, many states have joined together to form a “compact” where the

license in one state is recognized in another. States belonging to the compact passed legislation adopt- ing the terms of the agreement. Th e state in which the nurse resides is considered the home state, and license renewal occurs in the home state ( NCSBN , 2018a ).

Licensure may be mandatory or permissive. Permissive licensure is a voluntary arrangement whereby an individual chooses to become licensed to demonstrate competence. However, the license is not required to practice. In this situation a manda- tory license is not required to practice. Mandatory licensure requires a nurse to be licensed in order to practice. In the United States and Canada, licen- sure is mandatory.

Licensure by Endorsement If a state is not a member of the compact, nurses licensed in one state may obtain a license in another state through the process of endorsement. Each application is considered independently and is granted a license based on the rules and regula- tions of the state.

States diff er in the number of continuing edu- cation credits required, mandatory courses, and other educational requirements. Some states may require that nurses meet the current criteria for licensure at the time of application, whereas others may grant the license based on the criteria in eff ect at the time of the original license. When applying for a license through endorsement, a nurse should always contact the board of nursing for the state and ask about the exact requirements for licensure in that state. Th is information is usually found on the state board of nursing Web site.

NURSYS is a national database that houses information on licensed nurses. Nurses apply- ing for licensure by endorsement may verify their licenses through this database. Th e nurse ’ s license verifi cation is available immediately to the endors- ing board of nursing ( NCSBN , 2016 ). Not all states belong to NURSYS.

Qualifi cations for Licensure Th e basic qualifi cation for licensure requires graduation from an approved nursing program. In the United States, each state may add additional requirements, such as disclosures regarding health or medications that could aff ect practice. Most states require disclosure of criminal conviction.

chapter 1 ■ Characteristics of a Profession 7

Licensure by Examination A major accomplishment in the history of nursing licensure was the creation of the Bureau of State Boards of Nurse Examiners. Th e formation of this agency led to the development of an identical examination in all states. Th e original examination, called the State Board Test Pool Examination, was created by the testing department of the National League for Nursing (NLN). Th is was completed through a collaborative contract with the state boards. Initially, each state determined its own passing score; however, the states did eventually adopt a common passing score. Th e examination is called the NCLEX-RN ® and is used in all states and territories of the United States. Th is test is prepared and administered through a professional testing company.

NCLEX-RN ®

Th e NCLEX-RN ® is administered through com- puterized adaptive testing (CAT). Candidates need to register to take the examination at an approved testing center in the state in which they intend to practice. Because of a large test bank, CAT permits a variety of questions to be adminis- tered to a group of candidates. Candidates taking the examination at the same time may not neces- sarily receive the same questions. Once a candidate answers a question, the computer analyzes the response and then chooses an appropriate question to ask next. If the candidate answers the question correctly, the following question may be more dif- fi cult; if the candidate answers incorrectly, the next question may be easier.

In April 2016, the NCSBN released the updated test plan. Th e new test plan redistributed the percentages for each content area and updated the question format with increased use of technol- ogy that better simulated patient care situations. More updated information on the NCLEX® test plans may be found on the NCSBN Web site ( www.ncsbn.org ).

Political Infl uences and the Advance of Nursing Professionals

Nursing made many advances during the time of social upheaval and change. Th e passing of the Social Security Act in 1935 strengthened public

health services. Public health nursing found itself in an ideal position to step up and assume respon- sibility for providing care to dependent mothers and children, the blind, and disabled children ( Black, 2014 ). In 1965, under President Lyndon B. Johnson, amendments to the Social Security Act designed to ensure access to health care for the elder adult, the poor, and the disabled resulted in the creation of Medicare and Medicaid (Centers for Medicare and Medicaid Services [ CMS ], 2017 ). Health insurance companies emerged and increased in number during this time as well. Hos- pitals started to rely on Medicare, Medicaid, and insurance reimbursement for services. Care for the sick and new opportunities and roles emerged for nurses within this environment.

Historically, as a profession, nursing has made most of its advances during times of social change. Th e 1960s through the 1980s brought many changes for both women and nursing. In 1964, President Johnson signed the Civil Rights Act, which guaranteed equal treatment for all individ- uals and prohibited gender discrimination in the workplace. However, the law lacked enforcement. During this time, the feminist movement gained momentum, and the National Organization for Women was founded to help women achieve equality and give women a voice. Nursing moved forward as well. Specialty care disciplines devel- oped. Advances in technology gave way to the more complex medical–surgical treatments such as cardiothoracic surgery, complex neurosurgical techniques, and the emergence of intensive care environments to care for these patients. Th ese changes fostered the development of specializa- tion for nurses and physicians, creating a shortage of primary care physicians. Th e public demanded increased access to health care, and nursing again stepped forward by developing an advanced prac- tice role for nurses to meet the primary health-care needs of the public.

Th roughout the years, wars created situations that facilitated changes in nursing and its role within society. Wars increased the nation ’ s need for nurses and the public ’ s awareness of nursing ’ s role in society ( Kalisch & Kalisch, 2004 ). Nurses served in the military during both world wars and the Korean confl ict and changed nursing practice during the time of war. For the fi rst time, nurses were close to the front and worked in mobile hos- pital units. Often they lacked necessary supplies

8 unit 1 ■ Professionalism

and equipment ( Kalisch & Kalisch, 2004 ). Th ey found themselves in situations where they needed to function independently and make immediate decisions, often assuming roles normally associated with the physicians and surgeons.

Th e Vietnam War aff orded nurses opportunities to push beyond the boundaries as they functioned in mobile hospital units in the war theater, often without direct supervision of physicians. Th ese nurses performed emergency procedures such as tracheostomies and chest tube insertions in order to preserve the lives of the wounded soldiers ( Texas Tech University, 2017 ). After functioning inde- pendently in the fi eld, many nurses felt restricted by the practice limits placed on them when they returned home.

Challenges for society and nurses continued from the 1980s through 2000. Th e 1980s were marked by the emergence of the HIV virus and AIDS. Although we know more about HIV and AIDs today than we knew more than 30 years ago, society ’ s fear of the disease stigmatized groups of individuals and created fear among global popu- lations and health-care providers. Nurses became instrumental in educating the public and working directly with infected individuals.

Th e increase in available technology allowed for the widespread use of life-support systems. Nurses working in critical care areas often faced ethical dilemmas involving the use of these tech- nologies. During this time period, nurses voiced their opinions and concerns and helped in formu- lating policies addressing these issues within their communities and institutions. Th e fi eld of hospice nursing received a renewed interest and support (National Hospice and Palliative Care Organi- zation [ NHPCO ], 2012 ); therefore, the number of hospice care providers grew and opened new opportunities for nurses.

Th e fi rst part of the 21st century introduced nurses to situations beyond anyone ’ s imagina- tion. Nursing ’ s response to the terrorist attack on the World Trade Center and during the onset and aftermath of Hurricane Katrina raised mul- tiple questions regarding nurses’ abilities to react to major disasters. Nurses, physicians, and other health-care providers attempted to care for and protect patients under horrifi c conditions. Nurses found themselves trying to function “during unfa- miliar and unusual conditions with the health care environment that may necessitate adaptations

to recognized standards of nursing practice” (American Nurses Association [ ANA ], 2006 ).

Nursing has recognized the need for the profession to understand and function during human-caused and natural disasters such as 9/11 and hurricanes. Th e profession has answered the call by increasing disaster preparedness training for nurses.

Nursing and Health-Care Reform

For more than 40 years, Florence Nightingale played an infl uential part in most of the important health-care reforms of her time. Her accomplish- ments went beyond the scope of nursing and nursing education, aff ecting all aspects of health care and social reform.

Nightingale contributed to health-care reform through her work during the Crimean War, where she greatly improved the health and well-being of the British soldiers. She kept accurate records and accountings of her interventions and outcomes, and on her return to England she continued this work and reformed the conditions in hospitals and health care.

Th e 21st century brings both challenges and opportunities for nursing. It is estimated that more than 434,000 nurses will be needed by the year 2024 (Bureau of Labor Statistics [ BLS ], 2017 ). Th e severe nursing shortage has increased the demand for more nurses, whereas the passing of the Aff ordable Care Act (ACA) off ers oppor- tunities for nurses to take the lead in providing primary health care to those who need it. More advanced practice nurses will be needed to address the needs of the diverse population in this country. Health-care reform is discussed in more detail in Chapter 16 .

Nursing Today

Issues specifi c to nursing refl ect the problems and concerns of the health-care system as a whole. Th e average age of nurses in the United States is 46.8 years, and approximately 50% of the nursing workforce is older than 50 ( NCSBN, 2015 ). Because of changes in the economy, many nurses who planned to retire have instead found it nec- essary to remain in the workforce. However, the recent data collected also noted an increase in men

chapter 1 ■ Characteristics of a Profession 9

entering the fi eld as well as an increase in younger and more diverse populations seeking nursing careers.

Concerns about the supply of registered nurses (RNs) and staffi ng shortages persist in both the United States and abroad. For the fi rst time, multi- ple generations of nurses fi nd themselves working together within the health-care environment. Th e oldest of the generations, the early baby boomers, planned to retire during the last several years; however, economics have forced many to remain in the workplace. Th ey presently work alongside Generation X (born between 1965 and 1979) and the generation known as the millennials (born in 1980 and later). Nurses from the baby boomer generation and Generation X provide the major- ity of bedside care. Where the millennials fi nd themselves comfortable with technology, the baby boomers feel the “old ways” worked well.

Generational issues in the nursing workforce present potential confl icts in the work environ- ment as these generations come with diff ering viewpoints as they attempt to work together within the health-care community ( Bragg, 2014 ; Moore, Everly, & Bauer, 2016 ). Each generation brings its own set of core values to the workplace. In order to be successful and work together as cohesive teams, each generation needs to value the others’ skills and perspectives. Th is requires active and assertive communication, recognizing the individual skill sets of the generations, and placing individuals in positions that fi t their specifi c characteristics.

Th e related issues of excessive workload, man- datory overtime, scheduling, abuse, workplace violence, and lack of professional autonomy con- tribute to the concerns regarding the nursing shortage ( Clarke, 2015 ; Wheatley, 2017 ). Th ese issues impact the workplace environment and often place patients at risk. Professional behavior requires respect and integrity, as well as safe practice.

The Future of Professional Nursing

Th e changes in health care and the increased need for primary care providers has opened the door for nursing. Th e Institute of Medicine (IOM , 2010 ) report specifi cally stated that nurses should be permitted to practice to the full extent of their education. Nurses are educated to care for individ- uals who have chronic illnesses and need health teaching and monitoring.

Advanced practice nurses (APRNs) are qual- ifi ed to diagnose and treat certain conditions. Th ese highly educated nurses are more than phy- sician extenders as they sit for board certifi cation examinations and are licensed by the states in which they practice. Educational requirements for APRNs include a minimum of a master ’ s degree in nursing with a clinical focus, and a designated number of clinical hours. Many nurse practition- ers are obtaining the Doctor of Nursing Practice (DNP) degree. Th e American Association of Crit- ical Care Nurses (AACN) and the NLN both promote this as the terminal degree for nurse practitioners. Areas of advanced practice include family nurse practitioner, acute care nurse prac- titioner, pediatric nurse practitioner, and certifi ed nurse midwife.

Conclusion

Professional behavior is an important component of nursing practice. It is outlined and guided by state nurse practice acts, the ethical codes, and standards of practice. Acting professionally both while in the workplace and in one ’ s personal life is also an expectation. As nursing moves forward in the 21st century, the need for committed profes- sionals and innovative nurse leaders is greater than ever. Society ’ s demand for high-quality health care at an aff ordable cost is now law and an impetus for change in how nurses function in the new environment.

Employers, colleagues, and peers depend on new nurses to act professionally and provide safe, quality patient care. Taking advantage of expand- ing educational opportunities, engaging in lifelong learning, and seeking certifi cation in a specialty demonstrate professional commitment.

Nursing has its roots as a calling and vocation. It originated in the community, moved to hospi- tals, returned to the community, and is now seen in multiple practice settings. Th e ACA has opened doors for more opportunities for nurses, and the IOM report on the Future of Nursing states that nurses need to be permitted to use their educa- tional skills in the health-care environment.

Often students ask the question: “So what can I do? I am a new graduate.” Get involved in your profession by joining organizations and becoming politically active. Continue pursuing excellence and set the stage for those who will come after you.

10 unit 1 ■ Professionalism

Study Questions

1. Read Notes on Nursing: What It Is and What It Is Not by Florence Nightingale. How much of its content is still true today?

2. What is your defi nition of nursing? How does it compare or contrast with Virginia Henderson ’ s defi nition?

3. Review the mission and purpose of the ANA or another national nursing organization online. Do you believe that nurses should belong to these organizations? Explain your answer.

4. Professional behaviors include a commitment to lifelong learning. What does “lifelong learning” mean beyond mandatory continuing education?

5. Formulate your plan to prepare for the NCLEX®.

Case Studies to Promote Critical Reasoning

Case I Th omas went to nursing school on a U.S. Public Health Service scholarship. He has been directed to go to a rural village in a small Central American country to work in a local health center. Several other nurses have been sent to this village, and the residents forced them to leave.

Th e village lacks electricity and plumbing; water comes from in-ground wells. Th e villagers and children suff er from frequent episodes of gastrointestinal disorders.

1. How do you think Florence Nightingale would have approached these issues?

2. What do you think Th omas should do fi rst to gain the trust of the residents of the village?

3. Explain how APRNs would contribute to the health and welfare of the residents of the village.

Case II Th e younger nurses in your health-care institution have created a petition to change the dress code policy. Th ey feel it is antiquated and rigid. Rather than wearing uniforms or scrubs on the nursing units, they would prefer to wear more contemporary clothing such as khakis and nice shirts with the agency logo along with laboratory coats. Th e older-generation nurses feel that this will detract from the nursing image, as patients expect nurses to dress in uniforms or scrubs and this is what defi nes them as a “profession.”

1. What are your thoughts regarding the image of nursing and uniforms?

2. Do you feel that uniforms defi ne nurses? Explain your reasoning.

3. Explain the reasons certain generations may see this as a threat to their professionalism.

4. Which side would you support? Explain your answer with current research.

chapter 1 ■ Characteristics of a Profession 11

NCLEX®-Style Review Questions

1. Nursing has its origins with 1. Florence Nightingale 2. Th e Knights of Columbus 3. Religious orders 4. Wars and battles

2. Who stated that the “function of the nurse is to Help the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death)”? 1. Henderson 2. Rogers 3. Robb 4. Nightingale

3. You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A non-nursing colleague asks about this code. Which of the following statements best describes this code? 1. Improves communication between the nurse and the patient 2. Protects the patient ’ s right of autonomy 3. Ensures identical care to all patients 4. Acts as a guide for professional behaviors in giving patient care

4. Th e NCLEX® for nurses is exactly the same in every state in the United States. Th e examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Ensures that honest and ethical care is provided 4. Provides a minimal standard of knowledge for a registered nurse in practice

5. APRNs generally: Select all that apply. 1. Function independently 2. Function as unit directors 3. Work in acute care settings 4. Work in the university setting 5. Hold advanced degrees

6. Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. Th is is which type of education? 1. Continuing education 2. Graduate education 3. In-service education 4. Professional registered nurse education

7. Which of the following is unique to a professional standard of decision making? Select all that apply. 1. Weighs benefi ts and risks when making a decision 2. Analyzes and examines choices more independently 3. Concrete thinking 4. Anticipates when to make choices without others’ Helpance

12 unit 1 ■ Professionalism

8. Nursing practice in the 21st century is an art and science that focuses on: 1. Th e client 2. Th e nursing process 3. Cultural diversity 4. Th e health-care facility

9. Which of the following represent the knowledge and skills expected of the professional nurse? Select all that apply. 1. Accountability 2. Advocacy 3. Autonomy 4. Social networking 5. Participation in nursing blogs

10. Professional accountability serves the following purpose: Select all that apply. 1. To provide a basis for ethical decision making 2. To respect the decision of the client 3. To maintain standards of health 4. To evaluate new professional practices and reassess existing ones 5. To belong to a professional organization.

13

OUTLINE Values Morals Values and Moral Reasoning Value Systems How Values Are Developed Values Clarifi cation

Belief Systems

Ethics and Morals Ethics Ethical Theories Ethical Principles

Autonomy Nonmalefi cence Benefi cence Justice Fidelity Confi dentiality Veracity Accountability

Ethical Codes Virtue Ethics Nursing Ethics Organizational Ethics Ethical Issues on the Nursing Unit Moral Distress in Nursing Practice Ethical Dilemmas

Resolving Ethical Dilemmas Faced by Nurses Assessment Planning Implementation Assessment Current Ethical Issues Practice Issues Related to Technology

Technology and Treatment Technology and Genetics

DNA Use and Protection Stem Cell Use and Research Professional Dilemmas

Conclusion

OBJECTIVES After reading this chapter, the student should be able to: ■ Discuss ways individuals form values

■ Diff erentiate between laws and ethics

■ Explain the relationship between personal ethics and professional ethics

■ Examine various ethical theories

■ Explore the concept of virtue ethics

■ Apply ethical principles to an ethical issue

■ Evaluate the infl uence organizational ethics exerts on nursing practice

■ Identify an ethical dilemma in the clinical setting

■ Discuss current ethical issues in health care and possible solutions

chapter 2 Professional Ethics and Values

14 unit 1 ■ Professionalism

Doctors at the Massachusetts General Hospital for Children faced an ethical challenge when a pair of conjoined twins born in Africa arrived last year seeking surgery that could save only one of them. Th e twins were connected at the abdomen and pelvis, sharing a liver and bladder, and had three legs. An examination by doctors at the hospital determined that only one of the girls was likely to survive the surgery, but that if doctors did not act, both would die. Th e case had posed the hospital with the challenge both of ensuring that the parents understood the risks of the procedure and that the hundreds of medical professionals needed to perform the complex series of operations to separate the children were comfortable with the ethics of the situation ( Malone, 2017 ). Which child should live, and which child should die?

“iron lung”). During this period, Danish physi- cians invented a method of manual ventilation by placing a tube into the trachea of polio patients. Th is initiated the creation of mechanical venti- lation as we know it today. Th e development of mechanical ventilation required more intensive nursing care and patient observation. Th e care and monitoring of patients proved to be more effi cient when nurses kept patients in a single care area, hence the term intensive care.

Th e late 1960s brought greater technological advances. Open heart surgery, in its infancy at the time, became available for patients who were seri- ously ill with cardiovascular disease. Th ese patients required specialized nursing care and nurses specifi cally educated in the use of advancing tech- nologies. Th ese new therapies and monitoring methods provided the impetus for the creation of intensive care units and the critical care nursing specialty ( Vincent, 2013 ).

In the past, the vast majority of individuals receiving critical care services would have died. However, the development of new drugs and advances in biomechanical technology permit health-care personnel to challenge nature. Th ese advances have enabled providers to off er patients treatments that in many cases increase their life expectancy and enhance their quality of life. However, this progress is not without its shortcom- ings as it also presents new perplexing questions.

Th e ability to prolong life has created some heart-wrenching situations for families and complex ethical dilemmas for health-care pro- fessionals. Decisions regarding terminating life support on an adolescent involved in a motor vehicle accident, instituting life support on a 65-year-old productive father, or a mother becom- ing pregnant in order to provide stem cells for her older child who has a terminally ill disease are just a few examples. At what point do parents say good-bye to their neonate who was born far too early to survive outside the womb? Families and professionals face some of the most diffi cult ethical decisions at times such as these. How is death defi ned? When does it occur? Perhaps these questions need to be asked: “What is life? Is there a diff erence between life and living?”

To fi nd answers to these questions, health-care professionals look to philosophy, especially the branch that deals with human behavior. Th rough time, to Help in dealing with these issues, the fi eld

Th is is only one of many modern ethical dilem- mas faced by health-care personnel. If you were a member of the ethics committee, what decision might you make? How would you come to that decision? Which twin would live and which would die?

In previous centuries, health-care practitioners had neither the knowledge nor the technology to make determinations regarding prolonging life, sustaining life, or even creating life. Th e main function of nurses and physicians was to support patients and families through times of illness, help them toward recovery, or provide comfort until death. Th ere were very few complicated decisions such as “Who shall live and who shall die?” During the latter part of the 20th century and through the fi rst part of the 21st century, technological advances such as multiple-organ transplantation, use of stem cells, new biologically based pharmaceuticals, and sophisticated life-support systems created unique situations stimulating serious conversations and debates. Th e costs of these life-saving treatments and technologies presented new dilemmas as to who should provide and pay for them, as well as who should receive them.

Health care saw its fi rst technological advances during 1947 and 1948 as the polio epidemic raged through Europe and the United States. Th is dev- astating disease initiated the development of units for patients who required manual ventilation (the

chapter 2 ■ Professional Ethics and Values 15

of biomedical ethics (or simply bioethics) evolved. Th is subdiscipline of ethics, the philosophical study of morality, is the study of medical morality, which concerns the moral and social implications of health care and science in human life ( Nummi- nen, Repo, & Leino-Kilpi, 2017 ).

In order to understand biomedical ethics, it is important to appreciate the basic concepts of values, belief systems, ethical theories, and morality. Th e following sections will defi ne these concepts and then discuss ways nurses can help the interprofessional team and families resolve ethical dilemmas.

Values

Individuals talk about value and values all the time. Th e term value refers to the worth of an object or thing. However, the term values refers to how individuals feel about ideas, situations, and concepts. Merriam-Webster’s Collegiate Dictio- nary defi nes value as the “estimated or appraised worth of something, or that quality of a thing that makes it more or less desirable, useful” ( Merriam- Webster Dictionary, 2017 ). Values, then, are judg- ments about the importance or unimportance of objects, ideas, attitudes, and attributes. Individuals incorporate values as part of their conscience and worldview. Values provide a frame of reference and act as pilots to guide behaviors and Help people in making choices.

Morals Morals arise from an individual ’ s conscience. Th ey act as a guide for individual behavior and are learned through family systems, instruction, and socialization. Morals fi nd their basis within indi- vidual values and have a larger social component than values ( Ma, 2013 ). Th ey focus more on “good” versus “bad” behaviors. For example, if you value fairness and integrity, then your morals include those values, and you judge others based on your concept of morality ( Maxwell & Narvaez, 2013 ).

Values and Moral Reasoning Reasoning is the process of making inferences from a body of information and entails forming conclusions, making judgments, or making inferences from knowledge for the purpose of answering questions, solving problems, and formu- lating a plan that determines actions ( McHugh &

Way, 2018 ). Reasoning allows individuals to think for themselves and not to take the beliefs and judgments of others at face value. Moral reasoning relates to the process of forming conclusions and creating action plans centered on moral or ethical issues.

Values, viewpoints, and methods of moral reasoning have developed through time. Older worldviews have now emerged in modern history, such as the emphasis on virtue ethics or a focus on what type of person one would prefer to become ( McLeod-Sordjan, 2014 ). Virtue ethics are dis- cussed later in this chapter.

Value Systems A value system is a set of related values. For example, one person may value (believe to be important) societal aspects of life, such as money, objects, and status. Another person may value more abstract concepts such as kindness, charity, and caring. Values may vary signifi cantly, based on an individual ’ s culture, family teachings, and reli- gious upbringing. An individual ’ s system of values frequently aff ects how he or she makes decisions. For example, one person may base a decision on cost, whereas another person placed in the same situation may base the decision on a more abstract quality, such as kindness. Values fall into diff erent categories:

■ Intrinsic values are those related to sustaining life, such as food and water ( Zimmerman & Zalta, 2014 ).

■ Extrinsic values are not essential to life. Th ey include the value of objects, both physical and abstract. Extrinsic values are not an end in themselves but off er a means of achieving something else. Th ings, people, and material items are extrinsically valuable ( Zimmerman & Zalta, 2014 ).

■ Personal values are qualities that people consider important in their private lives. Concepts such as strong family ties and acceptance by others are personal values.

■ Professional values are qualities considered important by a professional group. Autonomy, integrity, and commitment are examples of professional values.

People ’ s behaviors are motivated by values. Indi- viduals take risks, relinquish their own comfort and security, and generate extraordinary eff orts

16 unit 1 ■ Professionalism

because of their values ( Zimmerman & Zalta, 2014 ). Patients who have traumatic brain injuries may overcome tremendous barriers because they value independence. Race car drivers may risk death or other serious injury because they value competition and winning.

Values also generate the standards by which people judge others. For example, someone who values work more than leisure activities will look unfavorably on a coworker who refuses to work throughout the weekend. A person who believes that health is more important than wealth would approve of spending money on a relaxing vacation or perhaps joining a health club rather than invest- ing the money.

Often people adopt the values of individu- als they admire. For example, a nursing student may begin to value humor after observing it used eff ectively with patients. Values provide a guide for decision making and give additional meaning to life. Individuals develop a sense of satisfaction when they work toward achieving values they believe are important ( Tuckett, 2015 ).

How Values Are Developed Values are learned ( Taylor, 2012 ). Ethicists attri- bute the basic question of whether values are taught, inherited, or passed on by some other mechanism to Plato, who lived more than 2,000 years ago. A recent theory suggests that values and moral knowledge are acquired much in the same manner as other forms of knowledge, through real-world experience.

Values can be taught directly, incorporated through societal norms, and modeled through behavior. Children learn by watching their parents, friends, teachers, and religious leaders. Th rough continuous reinforcement, children eventually learn about and then adopt values as their own. Because of the values they hold dear, people often make great demands on themselves and others, ignoring the personal cost. For example:

Values change with experience and maturity. For example, young children often value objects, such as a favorite blanket or toy. Older children are more likely to value a specifi c event, such as a family vacation. As children enter adolescence, they place more value on peer opinions than those of their parents. Young adults often place value on certain ideals such as heroism. Th e values of adults are formed from all these experiences as well as from learning and thought.

Th e number of values that people hold is not as important as what values they consider important. Choices are infl uenced by values. Th e way people use their own time and money, choose friends, and pursue a career are all infl uenced by values.

Values Clarifi cation Values clarifi cation is deciding what one believes is important. It is the process that helps people become aware of their values. Values play an important role in everyday decision making. For this reason, nurses need to be aware of what they do and do not value. Th is process helps them to behave in a manner that is consistent with their values.

Both personal and professional values infl u- ence nurses’ decisions ( McLeod-Sordjan, 2014 ). Understanding one ’ s own values simplifi es solving problems, making decisions, and developing better relationships with others when one begins to realize how others develop their values. Kirschen- baum ( 2011 ) suggested using a three-step model of choosing, prizing, and acting with seven sub- steps to identify one ’ s own values ( Box 2-1 ).

You may have used this method when making the decision to go to nursing school. For some people, nursing is a fi rst career; for others, a second career. Using the model in Box 2-1 , the valuing process is analyzed:

Niesa grew up in a family where educational achievement was highly valued. Not surpris- ingly, she adopted this as one of her own values. Niesa became a physician, married, and had a son, Dino. She placed a great deal of eff ort on teaching her son the necessary educational

skills in order to get him into the “best private school” in the area. As he moved through the program, his grades did not refl ect his mother ’ s great eff ort, and he felt that he had disap- pointed his mother as well as himself. By the time Dino reached 9 years of age, he had devel- oped a variety of somatic complaints such as stomach ailments and headaches.

chapter 2 ■ Professional Ethics and Values 17

1. Choosing After researching alternative career options, you freely choose nursing school. Th is choice was most likely infl uenced by such factors as educational achievement and abilities, fi nances, support and encouragement from others, time, and feelings about people.

2. Prizing Once the choice was made, you were satisfi ed with it and told your friends about it.

3. Acting You entered school and started the journey toward your new career. Later in your career, you may decide to return to school for a bachelor ’ s or master ’ s degree in nursing.

As you progressed through school, you proba- bly started to develop a new set of values—your professional values. Professional values are those established as being important in your practice. Th e values include caring, quality of care, and ethical behaviors ( McLeod-Sordjan, 2014 ).

Belief Systems

Belief systems are an organized way of think- ing about why people exist in the universe. Th e purpose of belief systems is to explain issues such as life and death, good and evil, and health and illness. Usually these systems include an ethical code that specifi es appropriate behaviors. People may have a personal belief system, participate in a religion that provides such a system, or follow a combination of the two.

Members of primitive societies worshipped events in nature. Unable to understand the science

of weather, for example, early civilizations believed these events to be under the control of someone or something that needed to be appeased. Th ere- fore, they developed rituals and ceremonies to pacify these unknown entities. Th ey called these entities “gods” and believed that certain behaviors either pleased or angered the gods. Because these societies associated certain behaviors with specifi c outcomes, they created a belief system that enabled them to function as a group.

As higher civilizations evolved, belief systems became more complex. Archeology has provided evidence of the religious practices of ancient civ- ilizations that support the evolution of belief systems ( Ball, 2015 ). Th e Aztec, Mayan, Incan, and Polynesian cultures had a religious belief system composed of many gods and goddesses for the same functions. Th e Greek, Roman, Egyptian, and Scandinavian societies believed in a hierarchal system of gods and goddesses. Although given various names by the diff erent cultures, it is very interesting that most of the deities had similar purposes. For example, the Greeks looked at Zeus as the king of the Greek gods, whereas Jupiter was his Roman counterpart. Th or was the king of the Norse gods. All three used a thunderbolt as their symbol. Sociologists believe that these religions developed to explain what was then unexplainable. Human beings have a deep need to create order from chaos and to have logical explanations for events. Religion off ers theological explanations to answer questions that cannot be explained by “pure science.”

Along with the creation of rites and rituals, reli- gions also developed codes of behaviors or ethical codes. Th ese codes contribute to the social order and provide rules regarding how to treat family members, neighbors, and the young and the old. Many religions also developed rules regarding marriage, sexual practices, business practices, prop- erty ownership, and inheritance.

For some individuals, the advancement of science has minimized their need for belief systems, as science can now provide explanations for many previously unexplainable phenomena. In fact, the technology explosion has created an even greater need for belief systems. Technologi- cal advances often place people in situations where they may welcome rather than oppose religious convictions to guide diffi cult decisions. Many reli- gions, particularly Christianity, focus on the will of

box 2-1

Values Clarifi cation Choosing 1. Choosing freely 2. Choosing from alternatives 3. Deciding after giving consideration to the

consequences of each alternative

Prizing 4. Being satisfi ed about the choice 5. Being willing to declare the choice to others

Acting 6. Making the choice a part of one ’ s worldview and

incorporating it into behavior 7. Repeating the choice

Source: Adapted from Raths, L. E., Harmon, M., & Simmons, S. B. (1979). Values and teaching. New York, NY: Charles E. Merrill.

18 unit 1 ■ Professionalism

a supreme being; technology, for example, is con- sidered a gift that allows health-care personnel to maintain the life of a loved one. Other religions, such as certain branches of Judaism, focus on free choice or free will, leaving such decisions in the hands of humankind. For example, many Jewish leaders believe that if genetic testing indicates that an infant will be born with a disease such as Tay-Sachs that causes severe suff ering and ulti- mately death, terminating the pregnancy may be an acceptable option.

Belief systems often help survivors in making decisions and living with them afterward. So far, technological advances have created more ques- tions than answers. As science explains more and more previously unexplainable phenomena, people need beliefs and values to guide their use of this new knowledge.

Ethics and Morals

Although the terms morals and ethics are often used interchangeably, ethics usually refers to a standard- ized code as a guide to behaviors, whereas morals usually refers to an individual ’ s personal code for acceptable behavior.

Ethics Ethics is the part of philosophy that deals with the rightness or wrongness of human behavior. It is also concerned with the motives behind that behavior. Bioethics , specifi cally, is the application of ethics to issues that pertain to life and death. Th e implication is that judgments can be made about the rightness or goodness of health-care practices.

Ethical Theories Several ethical theories have emerged to justify moral principles ( Baumane-Vitolina, Cals, & Sumilo, 2016 ). Deontological theories take their norms and rules from the duties that individuals owe each other by the goodness of the commit- ments they make and the roles they take upon themselves. Th e term deontological comes from the Greek word deon (duty). Th is theory is attributed to the 18th-century philosopher Immanuel Kant ( Kant, 1949 ). Deontological ethics considers the intention of the action. In other words, it is the individual ’ s good intentions or goodwill ( Kant, 1949 ) that determines the worthiness or goodness of the action.

Teleological theories take their norms or rules for behaviors from the consequences of the action. Th is theory is also called utilitarianism. Accord- ing to this concept, what makes an action right or wrong is its utility, or usefulness. Usefulness is considered to be the right amount of “happiness” the action carries. “Right” encompasses actions that result in good outcomes, whereas “wrong” actions end in bad outcomes. Th is theory origi- nated with David Hume, a Scottish philosopher. According to Hume, “Reason is and ought to be the slave of passions” (Hume, 1978, p. 212). Based on this idea, ethics depends on what people want and desire. Th e passions determine what is right or wrong. However, individuals who follow tele- ological theory disagree on how to decide on the “rightness” or “wrongness” of an action because individual passions diff er.

Principalism is an arising theory receiving a great deal of attention in the biomedical ethics community. Th is theory integrates existing ethical principles and tries to resolve confl icts by relating one or more of these principles to a given situation ( Hine, 2011 ; Varelius, 2013 ). Ethical principles actually infl uence professional decision making more than ethical theories.

Ethical Principles Ethical codes are based on principles that can be used to judge behavior. Ethical principles Help decision making because they are a standard for measuring actions. Th ey may be the basis for laws, but they themselves are not laws. Laws are rules created by governing bodies. Laws operate because the government holds the power to enforce them. Th ey are usually quite specifi c, as are the conse- quences for disobeying them. Ethical principles are not confi ned to specifi c behaviors. Th ey act as guides for appropriate behaviors. Th ey also con- sider the situation in which a decision must be made. Ethical principles speak to the essence of the law rather than to the exactness of the law. Here is an example:

Mrs. Gustav, 88 years old, was admitted to the hospital in acute respiratory distress. She was diagnosed with aspiration pneumonia and soon became septic, developing acute respiratory dis- tress syndrome (ARDS). She had a living will, and her attorney was her designated health-care

chapter 2 ■ Professional Ethics and Values 19

surrogate. Her competence to make decisions remained uncertain because of her illness. Th e physician presented the situation to the attor- ney, indicating that without a feeding tube and tracheostomy, Mrs. Gustav would die. Accord- ing to the laws governing living wills and health-care surrogates, the attorney could have made the decision to withhold all treatments. However, he believed he had an ethical obliga- tion to discuss the situation with his client. Th e client requested the tracheostomy be performed and the feeding tube inserted, which was done.

that a patient received insuffi cient information to make an appropriate choice, is being coerced into a decision, or lacks an understanding of the conse- quences of the choice, then the nurse may act as a patient advocate to ensure the principle of auton- omy ( Rahmani, Ghahramanian, & Alahbakhshian, 2010 ).

Sometimes nurses have diffi culty with the principle of autonomy because it also requires respecting another person ’ s choice, even when the nurse disagrees. According to the principle of autonomy, nurses may not replace a patient ’ s decision with their own, even when the nurses deeply believe that the patient made the wrong choice. Nurses may, however, discuss concerns with patients and ensure that patients considered the consequences of the decision before making it ( Rahmani et al., 2010 ).

Nonmalefi cence

Th e ethical principle of nonmalefi cence requires that no harm be done, either deliberately or unin- tentionally. Th is rather complicated word comes from Latin roots, non, which means not; male (pronounced mah-leh), which means bad; and facere, which means to do.

Th e principle of nonmalefi cence also requires nurses to protect individuals who lack the ability to protect themselves because of their physical or mental condition. An infant, a person under anesthesia, and a person suff ering from dementia are examples of individuals with limited ability to protect themselves from danger or those who may cause them harm. Nurses are ethically obligated to protect their patients when the patients are unable to protect themselves.

Often, treatments meant to improve patient health lead to harm. Th is is not the intention of the nurse or of other health-care personnel, but it is a direct result of treatment. Nosocomial infections because of hospitalization are harmful to patients. Th e nurses, however, did not deliberately cause the infection. Th e side eff ects of chemotherapy or radi- ation may also result in harm. Chemotherapeutic agents cause a decrease in immunity that may result in a severe infection, and radiation may burn or damage the skin. For this reason, many choose not to pursue treatments.

Th e obligation to do no harm extends to the nurse who for some reason is not functioning at an optimal level. For example, a nurse who is impaired

Following are several of the ethical principles that are most important to nursing practice: autonomy, nonmalefi cence, benefi cence, justice, fi delity, con- fi dentiality, veracity, and accountability. In some situations, two or more ethical principles may con- fl ict with each other, leading to an ethical dilemma. Making a decision under these circumstances causes diffi culty and often results in extreme stress for those who need to make the decision.

Autonomy

Autonomy is the freedom to make decisions for oneself. Th is ethical principle requires that nurses respect patients’ rights to make their own choices about treatments. Informed consent before treat- ment, surgery, or participation in research provides an example of autonomy. To be able to make an autonomous choice, individuals need to be informed of the purpose, benefi ts, and risks of the procedures. Nurses accomplish this by assessing the individuals’ understanding of the information provided to them and supporting their choices.

Closely linked to the ethical principle of auton- omy is the legal issue of competence. A patient needs to be deemed competent in order to make a decision regarding treatment options. When patients refuse treatment, health-care personnel and family members who think diff erently often question the patient ’ s “competence” to make a decision. Of note is the fact that when patients agree with health providers’ treatment decisions, rarely is their competence questioned ( Shahriari, Mohammadi, Abbaszadeh, & Bahrami, 2013 ).

Nurses often fi nd themselves in a position to protect a patient ’ s autonomy. Th ey do this by pre- venting others from interfering with the patient ’ s right to proceed with a decision. If a nurse observes

20 unit 1 ■ Professionalism

by alcohol or drugs knowingly places patients at risk. According to the principle of nonmalefi cence, other nurses who observe such behavior have an ethical obligation to protect patients.

Benefi cence

Th e word benefi cence also comes from Latin: bene, which means well, and facere, which means to do.

Th e principle of benefi cence demands that good be done for the benefi t of others. For nurses, this means more than delivering competent physical or technical care. It requires helping patients meet all their needs, whether physical, social, or emo- tional. Benefi cence is caring in the truest sense, and caring fuses thought, feeling, and action. It requires knowing and being truly understanding of the situation and the thoughts and ideas of the individual ( Benner & Wruble, 1989 ).

Sometimes physicians, nurses, and families withhold information from patients for the sake of benefi cence. Th e problem with doing this is that it does not allow competent individuals to make their own decisions based on all available informa- tion. In an attempt to be benefi cent, the principle of autonomy is violated. Th is is just one example of the ethical dilemmas encountered in nursing prac- tice. For instance:

understand your role as a patient advocate. Con- sider the following questions:

1. To whom do you owe your duty: to the patient or the family?

2. How do you think you may be able to be a patient advocate in this situation?

3. What information would you communicate to the family members, and how could you Help them in dealing with their mother ’ s concerns?

Justice

Th e principle of justice obliges nurses and other health-care professionals to treat every person equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social standing ( John- stone, 2011 ). Th is principle also applies in the work and educational settings. Based on this principle, all individuals should be treated and judged by the same criteria. Th e following example illustrates this:

Mrs. Liu was admitted to the oncology unit with ovarian cancer. She is scheduled to begin chemotherapy treatments. Her two children and her husband have requested that the physician ensure that Mrs. Liu not be told her diagnosis because they believe she would not be able to cope with it. Th e physician communicated this information to the nursing staff and placed an order in the patient ’ s electronic medical record (EMR). After the fi rst treatment, Mrs. Liu became very ill. She refused the next treatment, stating she did not feel sick until she came to the hospital. She asked the nurse what could possibly be wrong with her that she needed a medicine that made her sick when she did not feel sick before. She then said, “Only people who get cancer medicine get this sick! Do I have cancer?”

As the nurse, you understand the order that the patient not be told her diagnosis. You also

Mr. Laury was found on the street by the police, who brought him to the emergency department. He was assessed and admitted to a medical unit. Mr. Laury was in deplorable con- dition: His clothes were dirty and ragged, he was unshaven, and he was covered with blood. His diagnosis was chronic alcoholism, compli- cated by esophageal varices and end-stage liver disease. Several nursing students overheard the staff discussing Mr. Laury. Th e essence of the conversation was that no one wanted to care for him because he was “dirty and smelly,” and he brought this condition on himself. Th e students, upset by what they heard, went to the clinical faculty to discuss the situation. Th e clinical faculty explained that based on the ethical prin- ciple of justice, every individual has a right to good care despite his or her economic or social position.

Th e concept of distributive justice necessitates the fair allocation of responsibilities and advan- tages, especially in a society where resources may be limited. Considered an ethical principle, dis- tributive justice refers to what society, or a larger group, feels is indebted to its individual members regarding: (1) individual needs, contributions, and

chapter 2 ■ Professional Ethics and Values 21

responsibilities; (2) the resources available to the society or organization; and (3) the society ’ s or organization ’ s responsibility to the common good ( Capp, Savage, & Clarke, 2001 ). Increased health- care costs through the years and access to care have become social and political issues. In order to understand distributive justice, we must address the concepts of need, individual eff ort, ability to pay, contribution to society, and age (Zahedi et al., 2013).

Age has become a controversial issue as it leads to questions pertaining to quality of life ( Skedgel, Wailoo, & Akehurst, 2015 ). Th e other issue regarding age revolves around technology in neonatal care. How do health-care providers place a value on one person ’ s life being higher than that of another? Should millions of dollars be spent preserving the life of an 80-year-old man who vol- unteers in his community, plays golf twice a week, and teaches reading to underprivileged children, or should money be spent on a 26-week-old fetus that will most likely require intensive therapies and treatments for a lifetime, adding up to millions of health-care dollars? In the social and business world, welfare payments are based on need, and jobs and promotions are usually distributed on the basis of an individual ’ s contributions and achieve- ments. Is it possible to apply these measures to health-care allocations?

Philosopher John Rawls addressed the issues of fairness and justice as the foundation of social structures ( Ekmekci & Arda, 2015 ). Rawls addresses the issue of fair distribution of social goods using the idea of the original position to negotiate the principles of justice. Th e original position based on Kant ’ s ( 1949 ) social contract theory presents a hypothetical situation where individuals, known as negotiators, act as trustees for the interests of all individuals. Th ese individ- uals are knowledgeable in the areas of sociology, political science, and economics. However, this position places certain limitations on them known as the veil of ignorance, which eliminates informa- tion about age, gender, socioeconomic status, and religious convictions. With the absence of this information, the vested interests of all parties dis- appear. According to Rawls, in a just society the rights protected by justice are not political bar- gaining issues or subject to the calculations of social interests. Simply put, everyone has the same rights and liberties ( Ekmekci & Arda, 2015 ).

Fidelity

Th e principle of fi delity requires loyalty. It is a promise that the individual will fulfi ll all commit- ments made to himself or herself and to others. For nurses, fi delity includes the professional ’ s loyalty to fulfi ll all responsibilities and agreements expected as part of professional practice. Fidelity is the basis for the concept of accountability—taking respon- sibility for one ’ s own actions ( Ostlund, Backstrom, Lindh, Sundin, & Saveman, 2015 ).

Confi dentiality

Th e principle of confi dentiality states that any- thing patients say to nurses and other health-care providers must be held in the strictest confi dence. Confi dentiality presents both an ethical and legal issue. Exceptions only exist when patients give permission for the sharing of information or when the law requires the release of specifi c information. Sometimes simply sharing information without revealing an individual ’ s name can be a breach of confi dentiality if the situation and the individual are identifi able.

Nurses come into contact with people from all walks of life. Within communities, individuals know other individuals who know others, creating “micro-communities” of information. Individu- als have lost families, employment, and insurance coverage because nurses shared confi dential in- formation and others acted on that knowledge ( Beltran-Aroca, Girela-Lopez, Collazo-Chao, Montero-Pérez-Barquero, & Muñoz-Villanueva, 2016 ).

In today ’ s electronic environment, the princi- ple of confi dentiality has become a major concern, especially in light of the security breaches that have occurred throughout the last several years. Many health-care institutions, insurance companies, and businesses use electronic media to transfer sensi- tive and confi dential information, allowing more opportunities for a breakdown in confi dential- ity. Health-care institutions and providers have attempted to address the situation through the use of passwords, limited access, and cybersecurity. However, it has become more apparent that the securest of systems remain vulnerable to hacking and illegal access.

Veracity

Veracity requires nurses to be truthful. Truth is fundamental to building a trusting relationship.

22 unit 1 ■ Professionalism

Intentionally deceiving or misleading a patient is a violation of this principle. Deliberately omitting a part of the truth is deception and violates the prin- ciple of veracity. Th is principle often creates ethical dilemmas. When is it permissible to lie? Some ethicists believe it is never appropriate to deceive another individual. Others think that if another ethical principle overrides veracity, then lying is acceptable ( Sokol, 2007 ). Consider this situation:

Th e idea of a standard of care evolves from the principle of accountability. Standards of care provide a rule for measuring nursing actions and safety issues. According to the Institute of Medi- cine (IOM), organizations also hold accountability for patient care and the actions of personnel. Based on the Institute for Healthcare Improvement (IHI), health-care organizations have a duty to ensure a safe environment and that all personnel receive appropriate training and education ( IHI, 2018 ).

Ethical Codes A code of ethics is a formal statement of the rules of ethical behavior for a particular group of indi- viduals. A code of ethics is one of the hallmarks of a profession. Th is code makes clear the behavior expected of its members.

Th e American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements ( Olsen & Stokes, 2016 ) provides values, standards, and principles to help nursing function as a pro- fession. Th e ANA developed the original code in 1985; it has gone through several revisions during

Ms. Allen has been told that her father suff ers from Alzheimer ’ s disease. Th e nurse practitioner wants to come into the home to discuss treat- ment options. Ms. Allen refuses, explaining that under no circumstances should the nurse prac- titioner tell her father the diagnosis. Ms. Allen bases her concern on past statements made by her father. She explains to the nurse practi- tioner that if her father fi nds out his diagnosis, he will take his own life. Th e nurse practitioner provides information on the newest treatments and available medications that might help. However, these treatments and medications are only available through a research study. To participate in the study, the patient needs to be aware of the benefi ts and the risks. Ms. Allen continues refusing to allow anyone to tell her father his diagnosis because of her certainty that he will commit suicide.

Th e nurse practitioner faces a dilemma: Does he abide by Ms. Allen ’ s wishes based on the principle of benefi cence, or does he abide by the principle of veracity and inform his patient of the diagno- sis? If he goes against Ms. Allen ’ s wishes and tells the patient his diagnosis, and he commits suicide, has nonmalefi cence been violated? Did the practi- tioner ’ s action cause harm? What would you do in this situation?

Accountability

Accountability is linked to fi delity and means accepting responsibility for one ’ s own actions. Nurses are accountable to their patients and to their colleagues. When providing care to patients, nurses are responsible for their actions, good and poor. If something was not done, do not chart it and tell a colleague that it was completed. An example of violating accountability is the story of Anna:

Anna was a registered nurse who worked nights on an acute care medical unit. She was an excellent nurse; however, as the acuity of the patients’ conditions increased, she was unable to keep up with both patients’ needs and the tech- nology, particularly intravenous fl uids and lines. Th e pumps confused her, so often she would take the fl uids off the pump and “monitor her IVs” the way she did in the past. She started to document that all the IVs were infusing as they should, even when they were not. Each morning the day shift would fi nd that the actual infused amount did not agree with the documenta- tion, even though “pumps” were found for each patient. One night, Anna allowed an entire liter of intravenous fl uids to be infused in 2 hours into a patient who had heart failure. When the day staff came on duty, they found the patient expired, the bag empty, and the tubing fi lled with blood. Th e IV was attached to the pump. Anna ’ s documentation showed 800 mLs left in the bag. It was not until after a lawsuit was fi led that Anna assumed responsibility for her behavior.

chapter 2 ■ Professional Ethics and Values 23

the years since its development and may be viewed online at www.nursingworld.org .

Ethical codes remain subject to change. Th ey refl ect the values of the profession and the society for which they were developed. Changes occur as society and technology evolve. For example, years ago no thought was given to Do Not Resuscitate (DNR) orders or withholding food or fl uids. Tech- nological advances have since made it possible to keep people in a type of twilight life, comatose and unable to participate in living in any way, thus making DNR and withholding very important issues in health care. Technology and scientifi c advancements increased knowledge and skills, but the ability to make decisions regarding care con- tinues to be guided by ethical principles.

Virtue Ethics Virtue ethics focuses on virtues or moral character, rather than on duties or rules that emphasize con- sequences of actions. Consider the following:

Nursing Ethics Up to this point, the ethical principles discussed apply to ethics for nurses; however, nurses do not customarily fi nd themselves enmeshed in the bio- medical ethical decision-making processes that gain attention. Th e ethical principles that guide nursing practice are rooted in the philosophy and science of health care.

Relationships are the center of nursing ethics. Nursing ethics, viewed from the perspective of nursing theory and practice, deals with the experi- ences and needs of nurses and their perceptions of these experiences ( Johnstone, 2011 ).

Organizational Ethics Organizational ethics focus on the workplace at the organizational level. Every organization, even one with hundreds of thousands of employees, consists of individuals. Each individual makes his or her own decisions about how to behave in the workplace ( Carucci, 2016 ), and every person has the opportunity to make an organization a more or less ethical place. Th ese individual decisions exert a powerful eff ect on the lives of many others in the organization as well as the surrounding community.

Most organizations create a set of values that guide the organizational ideals, practices, and expectations ( Leonard, 2018 ). Although given varying “names,” such as core values, practice values, and so on, they lay the groundwork for expectations for employees. What is most import- ant is that employees see that the organization practices what it states. Leadership, especially senior leadership, is the most critical factor in pro- moting an ethical culture.

When looking for a professional position, it is important to consider the organizational culture and ethical guides. What are the values and beliefs of the organization? Do they blend with yours, or are they in confl ict with your value system? To discover this information, look at the organiza- tion ’ s mission, vision, and value statements. Speak with other nurses who work in the organization. Do they see consistency between what the orga- nization states and what it actually expects from employees? For example, if an organization states that it collaborates with the nurses in decision making, do nurses sit on committees that provide input toward the decision-making process ( Choi,

Carlos is driving along the highway and discov- ers a crying child sitting by a fallen bicycle. It is obvious that the child needs Helpance. From one ethical standpoint (utilitarianism), helping the child will increase Carlos’s feelings of “doing good.” Th e deontological stance states that by helping, Carlos is behaving in accordance with a moral rule such as “Do unto others. . . .” Virtue ethics looks at the fact that, by helping, Carlos would be acting charitable or benevolent.

Plato and Aristotle are considered the founders of virtue ethics. Its roots can be found in Chinese philosophy. During the 1800s, virtue ethics disap- peared, but in the late 1950s it re-emerged as an Anglo-American philosophy. Neither deontology nor utilitarianism considered the virtues of moral character and education and the question: “What type of person should I be, and how should I live” ( Sakellariouv, 2015 ). Virtues include qualities such as honesty, generosity, altruism, and reliability. Th ey are concerned with many other elements as well, such as emotions and emotional reactions, choices, values, needs, insights, attitudes, interests, and expectations. Nursing has practiced virtue ethics for many years.

24 unit 1 ■ Professionalism

Jang, Park, & Lee, 2014 )? Confl icts between a nurse ’ s professional values and those of the organi- zation result in moral distress for the nurse.

Ethical Issues on the Nursing Unit Organizational ethics refer to the values and expected behaviors entrenched within the orga- nizational culture. Th e nursing unit represents a subculture within a health-care organization. Ideally, the nursing unit should mirror the ethical atmosphere and culture of the organization. Th is requires the individuals who staff the unit to embrace the same values and model the expected behaviors ( Choi et al., 2014 ).

Confl icts with the values and ethics among individuals who work together on a unit often create issues that result in moral suff ering for some nurses. Moral suff ering occurs when nurses expe- rience a feeling of uneasiness or concern regarding behaviors or circumstances that challenge their own morals and beliefs ( Epstein & Hamric, 2009 ; Morley, 2016 ). Th ese situations may be the result of unit policies, physician ’ s orders that the nurse believes may not be benefi cial for the patient, professional behaviors of colleagues, or family atti- tudes about the patient ( Morley, 2016 ).

Perhaps one of the most disconcerting ethical issues nurses on the patient care unit face is the one that challenges their professional values and ethics. Friendships often emerge from work rela- tionships, and these friendships may interfere with judgments. Similarly, strong negative feelings may cloud a nurse ’ s ability to view a situation fairly and without prejudice. Consider the following:

When working with others, it is important to hold true to your personal values and moral stan- dards. Practicing virtue ethics, that is, “doing the right thing,” may cause diffi culty because of the possible consequences of the action. Nurses should support each other, but not at the expense of patients or each other ’ s professional duties. Th ere are times when not acting virtuously may cause a colleague more harm.

Moral Distress in Nursing Practice Moral distress occurs when nurses know the action they need to take, but for some reason fi nd them- selves unable to act (Fourie, 2015). Th is is usually the result of external forces or loyalties ( Hamric, 2014 ). Th erefore, the action or actions they take create confl ict as the decision goes against their personal and professional values, morals, and beliefs ( Morley, 2016 ). Th ese situations challenge nurses’ integrity and authenticity.

Studies have shown that nurses exposed to moral distress suff er from emotional and physical problems and eventually leave the bedside and the profession. Sources of moral distress vary; however, contributing factors include end-of-life challenges, nurse-physician confl icts, workplace bullying or violence, and disrespectful interactions ( Oh & Gastmans, 2015 ). Nursing organizations such as the American Association of Critical Care Nurses (AACN, 2018 ) have developed guidelines address- ing the issue of moral distress.

Ethical Dilemmas What is a dilemma? Th e word dilemma is of Greek derivation. A lemma was an animal resembling a ram and having two horns. Th us came the saying, “stuck on the horns of a dilemma.” Th e story of Hugo illustrates a hypothetical dilemma with a touch of humor:

Irina and James attended nursing school together and developed a strong friendship. Th ey work together on the pediatric surgical unit of a large teaching hospital. Th e hospital provides full tuition reimbursement for grad- uate education, so both decided to return to graduate school together and enrolled in a nurse practitioner program. Irina made a med- ication error that she decided not to report, an error that resulted in a child being transferred to the pediatric intensive care unit. James real- ized what happened and confronted Irina, who begged him not to say anything. James knew the error needed to be reported, but how would

this aff ect his friendship with Irina? Taking this situation to the other extreme, if a friendship had not been involved, would James react the same way? What would you do in this situation?

One day Hugo, dressed in a bright red cape, walked through his village into the countryside.

chapter 2 ■ Professional Ethics and Values 25

Similar to Hugo, nurses are often faced with diffi cult dilemmas. Also, as Hugo found, a dilemma can be a choice between two serious alternatives. An ethical dilemma occurs when a problem exists that forces a choice between two or more ethical principles. Deciding in favor of one principle will violate the other. Both sides have goodness and badness to them; however, neither decision satis- fi es all the criteria that apply ( Jie, 2015 ).

Ethical dilemmas also carry the added burden of emotions. Feelings of anger, frustration, and fear often override rational decision making. Consider the case of Mr. Rodney:

If you were Gloria, how might you respond? Depending on your answer, what ethical principles would be in confl ict here?

Resolving Ethical Dilemmas Faced by Nurses

Ethical dilemmas can occur in any aspect of life, personal or professional. Th is section focuses on the resolution of professional dilemmas. Th e various models for resolving ethical dilemmas consist of 5 to 14 sequential steps. Each step begins with a complete understanding of the dilemma and con- cludes with the Assessment of the implemented decision.

Th e nursing process provides a helpful mecha- nism for fi nding solutions to ethical dilemmas. Th e fi rst step is assessment, including identifi cation of the problem. Th e simplest way to do this is to create a statement that summarizes the issue. Th e remainder of the process evolves from this state- ment ( Box 2-2 ).

Assessment Ask yourself, “Am I directly involved in this dilemma?” An issue is not an ethical dilemma for nurses unless they fi nd themselves directly involved in the situation or have been asked for their opinion. Some nurses involved themselves

Th e wind caught the corners of his cape, and it was whipped in all directions. As he continued down the dusty road, Hugo happened to pass by a lemma. Hugo ’ s bright red cape caught the lemma ’ s attention. Lowering its head, with its two horns posed in attack position, the animal started chasing Hugo down the road. Panting and exhausted, Hugo reached the end of the road only to fi nd himself blocked by a huge stone wall. He turned to face the lemma, which was ready to charge. A decision needed to be made, and Hugo ’ s life depended on this deci- sion. If he moved to the left, the lemma would gore his heart. If he moved to the right, the lemma would gore his liver. No matter what his decision, Hugo would be “stuck on the horns of the lemma.”

Mr. Rodney, 85 years old, was admitted to the neuroscience unit after suff ering a left hemispheric bleed while playing golf with his friends. He had a total right hemiplegia and a Glasgow Coma Score of 8. He had been receiving intravenous fl uids for 4 days, and the neurologist raised the question of placing a jejunostomy tube for enteral feedings. Th e older of his two children asked what the chances of his recovery were. Th e neurologist explained that Mr. Rodney ’ s current state was proba- bly the best he could attain but that “miracles happen every day,” and that some diagnostic tests might help in determining the progno- sis. Th e family requested the tests. After the

results were available, the neurologist explained that the prognosis remained grave and that the intravenous fl uids were insuffi cient to sustain life. Th e jejunostomy tube would be a neces- sity if the family wished to continue with food and fl uids. After the neurologist left, the family asked the nurse, Gloria, who had been caring for Mr. Rodney during the previous 3 days, “If this was your father, what would you do?” Once the family asked Gloria this question, the situa- tion became an ethical dilemma for her as well.

box 2-2

Questions to Help Resolve Ethical Dilemmas

• What are the medical facts? • What are the psychosocial facts? • What are the patient ’ s wishes? • What values are in confl ict?

26 unit 1 ■ Professionalism

in situations even when no one solicited their opinion. Th is is generally unwarranted unless the issue involves a violation of the professional code of ethics.

Nurses are frequently in the position of hearing both sides of an ethical dilemma. Often individ- uals only want an empathetic listener. At other times, when guidance is requested, nurses can help people work through the decision-making process (remember the principle of autonomy) (Barlow, Hargreaves, & Gillibrand, 2018).

Collecting data from all the decision makers helps identify the reasoning process used by the individuals as they struggle with the issue. Th e following questions Help in the information- gathering process:

■ What are the medical facts? Find out how the physicians, nurse practitioners, and all members of the interprofessional health-care team view the patient ’ s condition and treatment options. Speak with the patient if possible, and determine his or her understanding of the situation.

■ What are the psychosocial facts? What is the emotional state of the patient right now? Th e patient ’ s family? What kind of relationship exists between the patient and his or her family? What are the patient ’ s living conditions? Who are the individuals who form the patient ’ s support system? How are they involved in the patient ’ s care? What is the patient ’ s ability to make medical decisions about his or her care? Do fi nancial considerations need to be taken into account? What does the patient value? What does the patient ’ s family value? Th e answers to these questions will provide a better understanding of the situation. Ask more questions, if necessary, to complete the picture. Th e social facts of a situation also include the institutional policies, legal aspects, and economic factors. Th e personal belief systems of the providers may also infl uence this aspect.

■ What are the cultural beliefs? Cultural beliefs play a major role in ethical decisions. Some cultures do not allow surgical interventions as they fear that the “life force” may escape. Many cultures forbid organ donation. Other cultures focus on the sanctity of life, thereby requesting that providers use all available methods for sustaining life.

■ What are the patient’s wishes? Remember the ethical principle of autonomy? With very few exceptions, if the patient is competent, his or her decisions take precedence. Too often, the family ’ s or provider ’ s worldview and belief system overshadow those of the patient. Nurses can Help by maintaining the focus on the patient. If the patient is unable to communicate, try to discover if the individual discussed the issue in the past. If the patient completed a living will or advance directives and designated a health-care surrogate, this helps determine the patient ’ s wishes. By interviewing family members, the nurse can often learn about conversations where the patient voiced his or her feelings about treatment decisions. Using guided interviewing, the nurse can encourage the family to share anecdotes that provide relevant insights into the patient ’ s values and beliefs.

■ What values are in confl ict? To assess values, begin by listing each person involved in the situation. Th en identify values represented by each person. Ask such questions as, “What do you feel is the most pressing issue here?” and “Tell me more about your feelings regarding this situation.” In some cases, there may be little disagreement among the people involved, just a diff erent way of expressing individual beliefs. However, in others, a serious value confl ict may exist.

Planning For planning to be successful, everyone involved in the decision must be included in the process. Th ompson and Th ompson ( 1992 ) listed three spe- cifi c and integrated phases of this planning:

1. Determine the goals of treatment Is cure a goal, or is the goal a peaceful death at home? Th ese goals need to be patient-focused, reality-centered, and attainable. Th ey should be consistent with current medical treatment and, if possible, measurable according to an established period.

2. Identify the decision makers As mentioned earlier, nurses may not be decision makers in these health-related ethical dilemmas. It is important to know who the decision makers are and their belief systems. A patient who has the capability to participate makes the

chapter 2 ■ Professional Ethics and Values 27

task less complicated. However, critically ill or terminally ill patients may be too exhausted to speak for themselves or ensure their voices are heard. When this happens, the patient needs an advocate, which might be family members, friends, spiritual advisors, or nurses. A family member may need to be designated as a primary decision maker or health-care surrogate. Th e creation of living wills, advance directives, and the appointment of a health-care surrogate while a person is healthy often eases the burden for the decision makers during a later crisis. Th ese are discussed in more detail in Chapter 3 .

3. List and rank all the options Performing this task involves all decision makers. It is sometimes helpful to begin with the least desired choice and methodically work toward the preferred treatment choice that will most likely produce the desired outcome. Engaging all participating parties in a discussion identifying each one ’ s beliefs regarding attaining a reasonable outcome using available medical expertise often helps. Often sharing ideas in a controlled situation allows everyone involved to realize that everyone wants the same goal but perhaps has varying opinions on how to reach it.

Implementation During the implementation phase, the patient or surrogate (substitute) decision maker(s) and members of the health-care team reach a mutu- ally acceptable decision. Th is occurs through open discussion and negotiation. An example of negoti- ation follows:

Th e role of the nurse during the implementa- tion phase is to ensure the communication remains open. Ethical dilemmas are emotional issues, fi lled with guilt, sorrow, anger, and other strong emo- tions. Th ese strong feelings create communication failures among decision makers. Remind yourself of the three ethical principles: autonomy, benefi – cence, and nonmalefi cence, and think, “I am here to do what is best for this patient.”

Keep in mind that an ethical dilemma is not always a choice between two attractive alternatives. Many dilemmas revolve around two unattractive, even unpleasant choices. In the previous scenario, Angela ’ s choices did not include what she truly wants: good health and a long life.

Once an agreement is reached, the decision makers must accept it. Sometimes an agreement cannot be reached because the parties are unable to reconcile their confl icting belief patterns or values. At other times, caregivers are unable to recognize the worth of the patient ’ s point of view. Occasion- ally, the patient or surrogate may make a request that is not institutionally or legally possible. When this occurs, a diff erent institution or physician may be able to honor the request. In some instances, a patient or surrogate may ask for information that refl ects illegal acts. When this happens, the nurse needs to explore whether the patient and the family considered the consequences of their proposed actions. Th is now presents a dilemma for the nurse as, depending on the request, he or she may need to notify upper-level administration or the authorities. Th is confl icts with the principle of confi dentiality. It may be necessary to bring other counselors into the discussion (with the patient ’ s permission) to negotiate the agreement.

Assessment As in the nursing process, the purpose of evalua- tion in resolving ethical dilemmas is to determine whether the desired outcomes have occurred. In

Olivia ’ s mother, Angela, has Stage IV ovarian cancer. She and Olivia have discussed treat- ment options. Angela ’ s physician suggested the use of a new chemotherapeutic agent that has demonstrated success in many cases. Angela states emphatically that she has “had enough” and prefers to spend her remaining time doing whatever she chooses. Olivia wants her mother to try the medication. To resolve the dilemma, the oncology nurse practitioner and physician speak with Olivia and her mother. Everyone

reviews the facts and expresses their feelings. Seeing Olivia ’ s distress, Angela says, “OK, I will try the drug for a month. If there is no improvement after this time, I want to stop all treatment and live out the time I have with my daughter and her family.” All agreed that this was a reasonable decision.

28 unit 1 ■ Professionalism

the case of Mr. Rodney, some of the questions that could be posed by Gloria to the family are as follows:

■ “I have noticed the amount of time you have been spending with your father. Have you observed any changes in his condition?”

■ “I see the neurologist spoke to you about the test results and your father ’ s prognosis. How do you feel about the situation?”

■ “Now that the neurologist spoke to you about your father ’ s condition, have you considered future alternatives?”

Changes in patient status, availability of medical treatment, and social factors may call for reevalu- ation of a situation. Th e course of treatment may need to be altered. Continued communication and cooperation among the decision makers are essential.

Another model, the MORAL model created by Th iroux in 1977 and refi ned for nursing by Halloran in 1992, has gained popularity and is considered a standard for dealing with ethical dilemmas ( Toren & Wagner, 2010 ). Th is ethical decision-making model is easily implemented in all patient care settings ( Box 2-3 ).

Current Ethical Issues Probably one of the most well-known events that brought attention to some of the ethical dilem- mas regarding end-of-life issues occurred in 1988 when Dr. Jack Kevorkian (sometimes called Dr. Death by the media) openly admitted to giving some patients, at their request, a lethal dose of medication, resulting in the patients’ deaths. His statement raised the consciousness of the Amer- ican people and the health-care system about the issues of euthanasia and Helped suicide. Do individuals have the right to consciously end their own lives when they are suff ering from a terminal

condition? If they are unable to perform the act themselves, should others Help them in ending their lives? Should Helped suicide be legalized? Physician-Helped suicide is currently legal in eight jurisdictions; Oregon was one of the fi rst states, and in 2018 Hawaii recognized this legal right with the passage of the Our Choice Act ( ProCon .org, 2018 ).

Th e Terri Schiavo case gained tremendous media attention, probably becoming the most important case of clinical ethics as it brought forward the deep divisions and fears that reside in society regarding life and death, as well as the role of the government and courts in these deci- sions ( Quill, 2005 ). Many aspects of the case may never be completely clarifi ed; however, it raised many questions that laid the groundwork for present ethical decisions in similar situations and beyond.

Th e primary goal of nursing and health-care professions is to keep people alive and well or, if this cannot be done, to help them live as com- fortably as possible and achieve a peaceful death. To accomplish this end, health-care professionals struggle to improve their knowledge and skills so they can care for their patients and provide the best quality of life possible. Th e costs involved in achieving this goal can be astronomical.

Questions are being raised more and more about who should receive the benefi ts of tech- nology. Th e competition for resources also creates ethical dilemmas. Other diffi cult questions, such as who should pay for care when the illness may have been caused by poor health practices such as smoking and substance abuse, are now under con- sideration. Many employers and health insurance companies evaluate the health status of individuals before determining the cost of their health-care premiums. For example, individuals who smoke or are overweight are considered to have a higher risk for chronic disease. Individuals with less risky behaviors and better health indicators may pay less for coverage ( CDC, 2015 ).

Practice Issues Related to Technology

Technology and Treatment

In issues of technology, the principles of benefi – cence and nonmalefi cence may be in confl ict. For example, a specifi c advancement in medical tech- nology administered with the intention of “doing

box 2-3

The MORAL Model

M : Massage the dilemma O : Outline the option R : Resolve the dilemma A : Act by applying the chosen option L : Look back and evaluate the complete process,

including actions taken

chapter 2 ■ Professional Ethics and Values 29

good” may cause harm. At times, this is an accepted consequence and the patient is aware of the risk. However, in situations where little or no improve- ment is expected, the issue becomes whether the benefi t outweighs the risk. Suff ering from induced technology may include multiple components for the patient and family.

Today, many infants born prematurely or with extremely low birthweights who long ago would have been considered unable to survive are maintained on mechanical devices in highly sophisticated neonatal units. Th is process may keep the infants alive only to die later or live with chronic, and often severe, disabilities. Th ese chil- dren require highly technological treatments and specialized medical, educational, and supportive services.

Th e use of ultrasound throughout a pregnancy is supported by evidence-based practice and is a standard of care. In the past, these pictures were mostly two-dimensional and used to determine fetal weight and size in relation to the moth- er ’ s pelvic anatomy. Today, this technology has evolved to where the fetus ’ s internal organ struc- ture is visualized, and defects not known before are detectable. Th is presents parents with additional options, leading to other decisions.

Technology and Genetics

Genetic diagnosis is a process that involves analyz- ing the parents or an embryo for a genetic disorder. Th is is done before in vitro fertilization. Once the egg is fertilized, the embryos are tested, and only those without genetic fl aws are implanted. Genetic screening of parents has also entered the standard of care, particularly in the presence of a family history. Parents are off ered this option when seeking prenatal care. Some parents refuse to have genetic testing as their value and belief systems preclude them from making a decision that may lead to terminating the pregnancy.

Genetic screening leads to issues pertain- ing to reproductive rights and also opens new issues. What is a disability versus a disorder, and who decides? Is a disability a disease, and does it need to be prevented? Th e technology is also used to determine whether individuals are pre- disposed to certain diseases such as Alzheimer ’ s or Huntington ’ s chorea. Th is has created addi- tional ethical issues regarding genetic screening. For example:

As the nurse, how might you address these concerns?

Genetic engineering is the ability to change the genetic nature of an organism. Researchers have created disease-resistant fruits and vegetables as well as certain medications using this process. Th eoretically, genetic engineering allows for the genetic alteration of an embryo, eliminating genetic fl aws and creating healthier babies. Envision being able to “engineer your child.” Imagine, as Aldous Huxley did in Brave New World ( 1932 ), being able to create a society of perfect individuals: “We also predestine and condition. We decant our babies as socialized human beings, as Alphas or Epsilons as future sewer workers or future . . . he was going to say future World controllers but correcting himself said future directors of Hatcheries instead” (p. 12). Th e ethical implications pertaining to genetic technology are profound. For example, some of the questions raised by the Human Genome Project related to:

■ Fairness in the use of genetic information ■ Privacy and confi dentiality of obtained genetic

information ■ Genetic testing of an individual because of a

family history

However, genetics has also allowed health-care providers to identify individuals who may have a greater risk for heart disease and diabetes and

Christy, who is 32 years old, is diagnosed with a nonhormonally dependent breast cancer. She has two daughters, ages 6 and 4 years old, respectively. Christy ’ s mother and mater- nal grandmother had breast cancer, and her maternal grandfather died from prostate cancer. Neither her mother nor grandmother survived more than 5 years post-treatment. Christy ’ s physician suggested she obtain genetic testing for the BRCA1 and BRCA2 genes before decid- ing on a treatment plan. Christy meets with the nurse geneticist and asks the following ques- tions: “If I am positive for the genes, what are my options? Should I have a bilateral mastec- tomy with reconstruction? Will I be able to get health insurance coverage, or will the company charge me a higher premium? What are the future implications for my daughters?”

30 unit 1 ■ Professionalism

begin early treatment and lifestyle changes to minimize or prevent the onset or complications of these disorders. Pharmacogenetics presently incorporates pharmacology and genetics and allows more targeted treatments for individuals by addressing their genetic makeup.

DNA Use and Protection Recently, Butler (2015) approached the subject of DNA use and protection. Presently, DNA is mostly used in forensic science for the identifi ca- tion of individuals, military personnel, or possible criminal evidence. However, questions remain as to the protection of this information and what is considered legal usage. Th e birth of companies that off er individuals the ability to discover their DNA and ancestral origins presents a greater level of concern both legally and ethically.

Stem Cell Use and Research Stem cell use and research issues have emerged during this decade. Stem cell transplants for the treatment of certain cancers are considered an acceptable treatment option when others have failed. Th ey are usually harvested from a match- ing donor. Th e ethics of stem cell use focuses on how to access them. Should fetal tissue be used to harvest stem cells? Companies now off er prospec- tive parents the option of obtaining and storing fetal cord blood and tissue for future use should the need arise. Although this is costly and not covered by insurance, many parents opt to do this.

When faced with the prospect of a child who is dying from a terminal illness, some parents have resorted to conceiving a sibling for the purpose of harvesting stem cells from the sibling to save the life of the ill child. Nurses who work in pediatrics and pediatric oncology units may fi nd them- selves dealing with this situation. It is important for nurses to examine their own feelings regard- ing these issues and understand that, regardless of their personal beliefs, the family is in need of sen- sitivity and the best nursing care.

Professional Dilemmas Most of this chapter dealt with patient issues; however, ethical problems may involve leadership

and management issues. What should you do about an impaired coworker? Personal loyalties may cause confl ict with professional ethics, creat- ing an ethical dilemma. For this reason, most nurse practice acts address this concern and require the reporting of impaired professionals while also pro- viding rehabilitation for those who need it.

Other professional dilemmas revolve around competence. How do you deal with incompetent health-care personnel? Th is situation frustrates both staff and management. Regulations created to protect individuals from unjustifi ed loss of position and the magnitude of paperwork, remediation, and the time it takes to terminate an incompetent health-care worker often compel management to tolerate the situation.

Employing institutions that provide nursing services have an obligation to establish a process for reporting and handling practices that jeop- ardize patient safety ( Gong, Song, Wu, & Hua, 2015 ). Th e behaviors of incompetent staff place patients and other staff members in jeopardy. Eventually, the incompetency may lead to legal action that could have been avoided if appropriate leadership pursued a diff erent approach.

Conclusion

Nurses and other health-care personnel fi nd them- selves confronting more ethical dilemmas in this ever-changing health-care environment. More questions are being raised with fewer answers available. New guidelines need to be developed to Help in fi nding viable solutions to these chal- lenging questions. Technology wields enormous power to alter the human organism, the promise to eradicate diseases that plague humankind, and the ability for health-care professionals to prolong human life. However, fi scal resources and econom- ics may force the health-care profession to rethink answers to questions such as, “What is life versus living?” and “When is it okay to terminate a human life?” Will society become the brave new world of Aldous Huxley? Again and again the question is raised, “Who shall live and who shall die?” How will you answer?

chapter 2 ■ Professional Ethics and Values 31

Study Questions

1. What is the diff erence between intrinsic and extrinsic values? Make a list of your intrinsic values.

2. Consider a decision you recently made that you based on your values. How did you make your choice?

3. Describe how you could use the valuing process of choosing, prizing, and acting in making the decision considered in Question 2.

4. Which of your personal values would be primary if you were assigned to care for an anencephalic infant whose parents have decided to donate the baby ’ s organs?

5. Th e parents of the anencephalic infant in Question 4 confront you and ask, “What would you do if this were your baby?” What do you think would be most important for you to consider in responding to them?

6. Your friend is single and feels that her “biological clock is ticking.” She decides to undergo in vitro fertilization using donor sperm. She tells you that she has researched the donor ’ s background extensively and wants to show you the “template” for her child. She asks for your professional opinion about this situation. How would you respond? Identify the ethical principles involved.

7. During the past several weeks, you have noticed that your closest friend, Jamie, has been erratic and making poor patient care decisions. On two separate occasions you quietly intervened and “fi xed” his errors. You have also noticed that he volunteers to give pain medications to other nurses’ patients, and you see him standing very close to other nurses when they remove controlled substances from the medication distribution system. Today, you watched him go to the center immediately after another colleague and then saw him go into the men ’ s room. Within about 20 minutes his behavior changed completely. You suspect that he is taking controlled substances. You and Jamie have been friends for more than 20 years. You grew up together and went to nursing school together. You realize that if you approach him, you may jeopardize this close friendship that means a great deal to you. Using the MORAL ethical decision-making model, devise a plan to resolve this dilemma.

Case Study to Promote Critical Thinking

Andy is assigned to care for a 14-year-old girl, Amanda, admitted with a large tumor located in the left groin area. During an assessment, Amanda shares her personal feelings with Andy. She tells him that she “feels diff erent” from her friends. She is ashamed of her physical development because all her girlfriends have “breasts” and boyfriends. She is very fl at-chested and embarrassed. Andy listens attentively to Amanda and helps her focus on some of her positive attributes and talents.

A computed tomography (CT) scan is ordered and reveals that the tumor extends to what appears to be the ovary. A gynecological surgeon is called in to evaluate the situation. An ultrasonic-guided biopsy is performed. It is discovered that the tumor is actually an enlarged lymph node, and the “ovary” is actually a testis. Amanda has both male and female gonads.

When the information is given to Amanda ’ s parents, they do not want her to know. Th ey feel that she was raised as “their daughter.” Th ey ask the surgeon to remove the male gonads and leave

32 unit 1 ■ Professionalism

NCLEX®-Style Review Questions

1. Several studies have shown that although care planning and advance directives are available to clients, only a minority actually complete them. Which of the following has been shown to be related to completing an advance directive? Select all that apply. 1. African American race 2. Younger age 3. History of chronic illness 4. Lower socioeconomic status 5. Higher education

2. Th e ANA Code of Ethics With Interpretive Statements guides nurses in ethical behaviors. Provision 3 of the ANA Code of Ethics says: “Th e nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” Which of the following best describes an example of this provision? 1. Respecting the patient ’ s privacy and confi dentiality when caring for him 2. Serving on a committee that will improve the environment of patient care 3. Maintaining professional boundaries when working with a patient 4. Caring for oneself before trying to care for another person

3. Health Insurance Portability and Accountability Act (HIPAA) regulations guard confi dentiality. In several situations, confi dentiality can be breached and information can be reported to other entities. Which of the following meet these criteria? Select all that apply. 1. Th e patient is from a correctional institution. 2. Th e situation involves child abuse. 3. An injury occurred from a fi rearm. 4. Th e patient is a physician. 5. Th e breach of information was unintentional.

4. A patient asks a nurse if he has to agree to the health provider ’ s treatment plan. Th e nurse asks the patient about his concerns. Which ethical principle is the nurse applying in this situation? Select all that apply. 1. Benefi cence 2. Autonomy 3. Veracity 4. Justice

only the female gonads. Th at way, “Amanda will never need to know.” Th e surgeon refuses to do this. Andy believes the parents should discuss the situation with Amanda as they are denying her choices. Th e parents are adamant about Amanda not knowing anything. Andy returns to Amanda ’ s room, and Amanda begins asking all types of questions regarding the tests and the treatments. Andy hesitates before answering, and Amanda picks up on this, demanding he tell her the truth.

1. How should Andy respond?

2. What ethical principles are in confl ict?

3. What are the long-term eff ects of Andy ’ s decision?

chapter 2 ■ Professional Ethics and Values 33

5. Which best describes the diff erence between patient privacy and patient confi dentiality? 1. Confi dentiality occurs between persons who are close, whereas privacy can aff ect anyone. 2. Privacy is the right to be free from intrusion into personal matters, whereas confi dentiality

is protection from sharing a person ’ s information. 3. Confi dentiality involves the use of technology for protection, whereas privacy uses physical

components of protection. 4. Privacy involves protection from being watched, whereas confi dentiality involves protection

from verbal exchanges.

6. A nurse is working on an ethics committee to determine the best course of action for a patient who is dying. Th e nurse considers the positive and negative outcomes of the decision to Help with choices. Which best describes the distinction of using a list when making an ethical decision? 1. Th e nurse can back up her reasons for why she has decided to provide a certain type of care. 2. Th e nurse can compare the benefi ts of one choice over another. 3. Th e nurse can communicate the best choice of action to the interdisciplinary team. 4. Th e nurse can provide care based on developed policies and standards.

7. A nurse is caring for a patient who feels that life should not be prolonged when hope is gone. She has decided that she does not want extraordinary measures taken when her life is at its end. She has discussed her feelings with her family and health-care provider. Th e nurse realizes that this is an example of: 1. Affi rming a value 2. Choosing a value 3. Prizing a value 4. Refl ecting a value

8. Which of the following demonstrates a nurse as advocating for a patient? Th e nurse 1. calls a nursing supervisor in confl icting situations. 2. reviews and understands the law as it applies to the client ’ s clinical condition. 3. documents all clinical changes in the medical record in a timely manner. 4. assesses the client ’ s point of view and prepares to articulate this point of view.

9. A nurse ’ s signifi cant other undergoes exploratory surgery at the hospital where the nurse is an employee. Which practice is most appropriate? 1. Th e nurse is an employee; therefore, access to the chart is permissible. 2. Access to the chart requires a signed release form. 3. Th e relationship with the client provides the nurse special access to the chart. 4. Th e nurse can ask the surgeon to discuss the outcome of the surgery.

10. A nurse is providing care to a patient whose family has previously brought suit against another hospital and two physicians. Under which ethical principle should the nurse practice? 1. Justice 2. Veracity 3. Autonomy 4. Nonmalefi cence

35

OUTLINE General Principles Meaning of Law Sources of Law

The Constitution Statutes Administrative Law

Types of Laws Criminal Law Civil Law

Tort Quasi-Intentional Tort Negligence Malpractice

Other Laws Relevant to Nursing Practice Good Samaritan Laws Confi dentiality Social Networking Slander and Libel False Imprisonment Assault and Battery

Standards of Practice Use of Standards in Nursing Negligence and Malpractice Actions Patient ’ s Bill of Rights Informed Consent

Staying Out of Court Prevention

Appropriate Documentation Common Actions Leading to Malpractice Suits If a Problem Arises

Professional Liability Insurance

End-of-Life Decisions and the Law Do Not Resuscitate Orders Advance Directives

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate)

Nursing Implications

Conclusion

OBJECTIVES After reading this chapter, the student should be able to: ■ Describe three major forms of laws

■ Identify the diff erences among the various types of laws

■ Clarify the criteria that determine negligence from malpractice

■ Diff erentiate between an intentional and an unintentional tort

■ Support the use of standards of care in determining negligence and malpractice

■ Explain how nurse practice acts protect the public

■ Diff erentiate between internal standards and external standards

■ Examine the role advance directives play in protecting client rights

■ Discuss the legal implications of the Health Insurance Portability and Accountability Act (HIPAA)

■ Identify legal issues surrounding the use of electronic medical records

chapter 3 Nursing Practice and the Law

36 unit 1 ■ Professionalism

Th e courtroom seemed cold and sterile. Scan- ning her surroundings with nervous eyes, Naomi knew how Alice must have felt when the Queen of Hearts screamed for her head. Th e image of the White Rabbit running through the woods, looking at his watch, yelling, “I ’ m late! I ’ m late!” fl ashed before her eyes. For a few moments, she indulged herself in thoughts of being able to turn back the clock and rewrite the past. Th e future certainly looked grim at that moment. Th e calling of her name broke her reverie. Ms. Cornish, the attorney for the plaintiff , wanted her undivided attention regarding the inauspicious day when she committed a fatal medication error. Th at day, the client died fol- lowing a cardiac arrest because Naomi failed to follow the standard of practice for administer- ing a chemotherapy medication. She removed the appropriate medication from the automated system; however, she made a calculation error and did not check this against the order. Her 15 years of nursing experience meant little to the court. She stood alone. She was being sued for malpractice, with the possibility of criminal charges should she be found guilty of contrib- uting to the client ’ s death.

a formal and legally binding manner. Laws are created in one of three ways:

1. Statutory laws are created by various legislative bodies, such as state legislatures or Congress. Some examples of federal statutes include the Patient Self-Determination Act of 1990 (PSDA), the Americans with Disabilities Act, and, more recently, the Aff ordable Care Act. State statutes include the state nurse practice acts and the Good Samaritan Act. Laws that govern nursing practice fall under the category of statutory law.

2. Common law is the traditional unwritten law of England, based on custom and use. It dates back to 1066 A.D. when William of Normandy won the Battle of Hastings ( Riches & Allen, 2013 ). Th is law develops within the court system as the judicial system makes decisions in various cases and sets precedents for future cases. A decision rendered in one case may aff ect decisions made in later cases of a similar nature. For this reason, one case sets a precedent for another.

3. Administrative law includes the procedures created by administrative agencies (governmental bodies of the city, county, states, or federal government) involving rules, regulations, applications, licenses, permits, hearings, appeals, and decision making. Th ese governing boards have the duty to meet the intent of laws or statutes.

Sources of Law

Th e Constitution

Th e U.S. Constitution is the foundation of Amer- ican law. Th e Bill of Rights, composed of the fi rst 10 amendments to the Constitution, laid the foun- dation for the protection of individual rights. Th ese laws defi ne and limit the power of government and protect citizens’ rights, such as freedom of speech, assembly, religion, and the press. Th ey also prevent the government from intruding into personal choices. State constitutions may expand individual rights but cannot limit nor deprive people of rights guaranteed by the U.S. Constitution.

Constitutional law evolves. As individuals or groups bring suits that challenge interpretations of the Constitution, decisions are made concerning the application of the law to that particular event. An example of this is the protection of “freedom of speech.” Is the use of obscenities protected?

As client advocates, nurses have a responsibility to deliver safe and eff ective care to their clients. Th is expectation requires nurses to have profes- sional knowledge at their expected level of practice and be profi cient in technical skills. A working knowledge of the legal system, client rights, and behaviors that may result in lawsuits helps nurses to act as client advocates. As long as nurses prac- tice according to the established standards of care, they may be able to avoid the kind of day in court Naomi experienced.

General Principles

Meaning of Law Th e word law holds several meanings. For the pur- poses of this chapter, law refers to any system of regulation that governs the conduct of individuals within a community or society, in response to the need for regularity, consistency, and justice ( Riches & Allen, 2013 ). In other words, law means those rules that prescribe and control social conduct in

chapter 3 ■ Nursing Practice and the Law 37

Can one person threaten or criticize another? Th e freedom to criticize is protected; however, threats are not. Th e defi nition of obscenity has been clar- ifi ed by the U.S. Supreme Court based on three separate cases. Th e decisions made in these cases evolved into what is referred to as the Miller test ( Department of Justice, 2015 ).

Statutes

Statutes are written laws created by a government or accepted governing body. Localities, state leg- islatures, and the U.S. Congress generate statutes. Local statutes are usually referred to as ordinances. Requiring all residents to use a specifi c city garbage bag is an example of a local ordinance.

At the federal level, conference committees comprising representatives of both houses of Con- gress negotiate the resolution of diff erences on the working of a bill before it is voted upon by both houses of Congress and sent to the president to be signed into law. If the bill does not meet with the approval of the executive branch of government, the president holds the right to veto it. If that occurs, the legislative branch needs enough votes to override the veto, or the bill will not become law.

Administrative Law

Federal agencies concerned with health-care– related laws include the Department of Health and Human Services (DHHS), the Department of Labor, and the Department of Education. Agen- cies that focus on health-care law at the state level involve state health departments and licensing boards.

Administrative agencies are staff ed with pro- fessionals who develop the specifi c rules and regulations that direct the implementation of statutory laws. Th ese rules need to be reasonable and consistent with existing statutory law and the intent of the legislature. Th e targeted individu- als and groups review and comment before these rules go into eff ect. For example, specifi c statutory laws give the state boards of nursing (SBONs) the authority to issue and revoke licenses. Th is means that each SBON holds the responsibility to oversee the professional nurse ’ s competence.

Types of Laws

Another way to view the legal system is to divide laws into categories, such as public law and private law. Public law encompasses state, constitutional,

administrative, and criminal law, whereas private law (civil law) covers contracts, torts, and property.

Criminal Law Criminal or penal law focuses on crime and pun- ishment. Societies created these laws to protect citizens from threatening actions. Criminal acts, although directed toward individuals, are consid- ered off enses against the state. Th e perpetrator of the act is punished, and the victim receives no compensation for injury or damages. Criminal law subdivides into three categories:

1. Felony: the most serious category, including such acts as homicide, grand larceny, and nurse practice act violations.

2. Misdemeanor: includes lesser off enses such as traffi c violations or shoplifting of a small dollar amount.

3. Juvenile: crimes carried out by individuals younger than 18 years of age; specifi c ages vary by state and crimes.

Th ere are occasions when a nurse breaks a law and is tried in criminal court. A nurse who obtains or distributes controlled substances illegally either for personal use or for the use of others is violating the law. Falsifi cation of records of controlled sub- stances is also a criminal action. In some states, altering a patient record may lead to both civil and criminal action depending on the treatment outcome ( Zhong, McCarthy, & Alexander, 2016 ). Although the following is an older case, it pro- vides an excellent example of negligence resulting in criminal charges brought against a nurse:

In New Jersey State v. Winter, Nurse V needed to administer a blood transfusion. Because she was in a rush, she neglected to check the paperwork properly and therefore failed to follow the established standard of practice for blood administration. Th e client was transfused with incompatible blood, suff ered a transfusion reaction, and died. Nurse V then intentionally attempted to conceal her conduct. She fal- sifi ed the records, disposed of the blood and administration equipment, and did not notify the client ’ s health-care provider of the error. Th e jury found Nurse V guilty of simple man- slaughter and sentenced her to 5 years in prison ( Sanbar, 2007 ).

38 unit 1 ■ Professionalism

Civil Law Civil laws usually involve the violation of one per- son ’ s rights by another person. Areas of civil law that particularly aff ect nurses are tort law, contract law, antitrust law, employment discrimination, and labor laws.

Tort

Th e remainder of this chapter focuses primarily on tort law. By defi nition, tort law consists of a body of rights, obligations, and remedies that courts apply during civil proceedings for the purpose of providing relief for individuals who suff ered harm from the wrongful acts of others. Tort laws serve two basic functions: (1) to compensate a victim for any damages or losses incurred by the defen- dant ’ s actions (or inaction) and (2) to discourage the defendant from repeating the behavior in the future ( LaMance, 2018 ). Th e individual who incurs the injury or damage is known as the plain- tiff , whereas the person who caused the injury or damage is referred to as the defendant. Tort law recognizes that individuals, in their relationships to one another, have a general duty to avoid harm. For example, automobile drivers have a duty to drive safely so that others will not be harmed. A construction company has a duty to build a structure that meets code and will not collapse, resulting in harm to individuals using it ( Viglucci & Staletovich, 2017 ). Nurses have a duty to deliver care in such a manner that the consumers of care are not harmed. Th ese legal duties of care may be violated intentionally or unintentionally.

Quasi-Intentional Tort

A quasi-intentional tort includes voluntary wrong- ful acts based on speech. Th ese are committed by a person or entity against another person or entity that infl icts economic harm or damage to rep- utation. For example, a defamation of character through slander or libel or an invasion of privacy is considered a quasi-intentional tort ( Garner, 2014 ).

Negligence

Negligence is an unintentional tort of acting or failing to act as an ordinary, reasonable, prudent person, resulting in harm to the person to whom the duty of care is owed ( Garner, 2014 ). For neg- ligence to occur the following elements must be present: duty, breach of duty, causation, and harm

or injury ( Jacoby & Scruth, 2017 ). All four ele- ments need to be present in the determination of negligence.

Nurses fi nd themselves in these situations when they fail to meet a specifi ed standard of practice or standard of care. Th e duty of care is the standard ( Wade, 2015 ). For example, if a nurse administers the incorrect medication to a client, but the client does not suff er any injury, the element of harm is not met. However, if a nurse administers the appropriate pain medication to a client and fails to raise the side rails and the client falls and breaks a hip, all four elements of negligence have been satisfi ed. Th e law defi nes the standard of care as that which any reasonable, prudent practitioner with similar education and experience would do or not do in a similar circumstance ( Jacoby & Scruth, 2017 ; Sanbar, 2007 ).

Malpractice

Malpractice is the term applied to professional neg- ligence (Sohn, 2013). Th is term is used when the fulfi llment of duties requires specialized education. In most malpractice suits, the facilities employing the nurses who cared for a client are named as the defendants in the suit. Th ese types of cases fall under the legal principle known as vicarious liabil- ity ( West, 2016 ).

Th ree doctrines come under the principle of vicarious liability: respondeat superior, the bor- rowed servant doctrine, and the “captain of the ship” doctrine. Th e captain of the ship doctrine, an adaptation of the borrowed servant rules, emerged from the case of McConnell v. Williams and refers to medical malpractice ( McConnell v. Williams, 1949 ). Th e ruling declared that the person in charge is held accountable for all those falling under his or her supervision, regardless of whether the “captain” is directly responsible for the alleged error or act of alleged negligence, and despite the others’ positions as hospital employees ( Stern, 1949 ).

An important principle in understanding negligence is respondeat superior (“let the master answer”) ( Th ornton, 2010 ). Th is doctrine holds employers liable for any negligence by their employees when the employees were acting under the scope of employment. Th e “borrowed servant” rules come into play when an employee may be subject to the control and direction of an entity other than the primary employer. In this

chapter 3 ■ Nursing Practice and the Law 39

particular situation, someone other than an indi- vidual ’ s primary employer is held accountable for his or her actions. Th is was the basis for the ruling in McConnell v. Williams and its application to the captain of the ship doctrine. Consider the follow- ing scenario:

Confi dentiality It is possible for nurses to fi nd themselves involved in lawsuits other than those involving negligence. For example, clients have the right to confi denti- ality, and it is the duty of the professional nurse to ensure this right ( Guglielmo, 2013 ). Th is assures the client that information obtained by a nurse while providing care will not be communicated to anyone who does not have a need to know. Th is includes giving information without a cli- ent ’ s signed release or removing documents from a health-care provider with a client ’ s name or other information.

Th e Health Insurance Portability and Account- ability Act (HIPAA) of 1996 was passed as an eff ort to preserve confi dentiality, protect the privacy of health information, and improve the portability and continuation of health-care cover- age. Th e HIPAA gave Congress until August 1999 to pass this legislation. Congress failed to act, and the DHHS took over developing the appropriate regulations ( Charters, 2003 ). Th e latest version of HIPAA can be found on the Health and Human Services Web site at www.hhs.gov .

Th e increased use of electronic medical records (EMRs) and transfer of client information pre- sents many confi dentiality issues. It is important for nurses to be aware of the guidelines protecting the sharing and transfer of information through electronic sources. Although most health-care insti- tutions have internal procedures to protect client confi dentiality, recently, several major health-care organizations found themselves victims of hacking and were held accountable for the dissemination of private information. However, it is exceptionally diffi cult to fi le lawsuits for these types of breaches ( Worth, 2017 ).

Consider the following example:

A nursing clinical faculty instructed his stu- dents not to administer any medication without his direct supervision. Marcos, a second-level student, was unable to fi nd the faculty, so he decided to administer digoxin to his client without faculty supervision. Th e ordered dose was 0.125 milligrams. He requested that one of the nurses access the automated medication dispensing system for him. Th e unit dose came as 0.5 milligrams/milliliter. Marcos adminis- tered the entire amount of medication without checking the dose, the client ’ s digoxin level, and the potassium levels. Th e client became toxic, developed a dysrhythmia, and was transferred to the intensive care unit. Th e family sued the hospital and the nursing school for malprac- tice. Th e clinical faculty was also sued under the principle of respondeat superior, even though specifi c instructions were given to students regarding administering medications without direct faculty supervision.

Other Laws Relevant to Nursing Practice

Good Samaritan Laws Fear of being sued often prevents trained profes- sionals from providing Helpance in emergency situations. To encourage physicians and nurses to respond to emergencies, many states developed what are now known as Good Samaritan laws. Th ese laws protect health-care professionals from civil liability as long as they behave in the same manner as an ordinary reasonable and prudent professional in the same or similar circumstances. In other words, the professional standards of care still apply. However, if the provider receives a payment for the care given, the Good Samaritan laws do not hold.

Evan was admitted to the hospital for pneu- monia. With Evan ’ s permission, an HIV test was performed, and the result was positive. Th is information was available on the computer- ized laboratory printout. A nurse inadvertently left the laboratory results up on the computer screen, which partially faced the hallway. One of Evan ’ s coworkers, who had come to visit him, saw the report on the screen and reported

40 unit 1 ■ Professionalism

Social Networking Another issue aff ecting confi dentiality involves social networking. Th e defi nition of social media is extensive and consistently changing. Th e term usually refers to Internet-based tools that permit individuals and groups to meet and communicate; to share information, ideas, personal messages, images, and other content; and to collaborate with other users in real time ( Ventola, 2014 ). Social media use is widespread across all ages and profes- sions and is universal throughout the world.

Social media modalities provide health-care professionals with Internet-based methods that Help them in sharing information; engaging in discussions on health-care policy and practice issues; encouraging healthy behaviors; connecting with the public; and educating and interacting with patients, caregivers, students, and colleagues ( Ventola, 2014 ). Th ese modalities convey infor- mation about a person ’ s personality, values, and priorities, and the fi rst impression generated by this content can be lasting ( Bernhardt, Alber, & Gold, 2014 ).

Employers, academic institutions, and other organizations often view social media content and develop perceptions about prospective employ- ees, students, and possible clientele based on this content ( Denecke et al., 2015 ). A person who consciously posts personal information on social media sites has willingly given access to anyone to view it for any purpose. Th erefore, it is only logical that those who do not use discretion in deciding what content to post online may also be unable to exercise sensible professional judgment.

Several years ago Microsoft conducted a survey revealing that 79% of employers accessed online information regarding potential employees, and only 7% of job candidates knew of this possibility ( MacMillan, 2013 ).

However, the increased use of social network- ing comes with a downside. A major threat centers on issues such as breaches of confi dentiality and defamation of character. Th e posting of unpro- fessional content has the potential to damage the reputations of health-care professionals, students, and affi liated institutions. Recently, a surgeon posted videos of herself dancing in the operating room while engaged in performing surgery on patients. A mishap occurred during one of the surgeries, and the patient suff ered a respiratory arrest. Patients and the public saw the videos, and therefore several malpractice suits have been fi led against the physician ( Hartung, 2018 ).

Behaviors associated with unprofessional actions include violations of patient privacy; the use of profanity or biased language; images of sexual impropriety or drunkenness; and inappro- priate comments about patients, an employer, or a school ( Peck, 2014 ). Nursing boards have also disciplined nurses for violations involving online disclosure of patients’ personal health information and have imposed sanctions ranging from letters of concern to license suspensions ( MacMillan, 2013 ). In 2009, a U.S. District Court upheld the expul- sion of a nursing student for violating the school ’ s honor code because the student made off ensive comments regarding the race, sex, and religion of patients ( Peck, 2014 ). More information about social media guidelines is available at www.social- mediagovernance.com . Th is resource includes 247 social media policies, many for health-care institutions or professional societies, such as the Mayo Clinic, Kaiser Permanente, and the Ameri- can Nurses Association (ANA; Grajales, Sheps, Ho, Novak-Lauscher, & Eysenbach, 2014 ).

Th e increased use of smartphones has led to increased violations of confi dentiality ( Ventola, 2014 ). Th ese infractions often occur without intent yet pose a risk to both clients and health-care per- sonnel. Posting pictures and information on social networking sites that involve clinical experiences or work experiences can present a risk to patient confi dentiality and violate HIPAA regulations. To comply with the HIPAA Privacy Rule, clinical information or stories posted on social media that deal with clients or patients must have all personal identifying information removed. Th e HIPAA Privacy Rule places heavy fi nancial penalties and possible criminal charges on the unautho- rized release of individually identifi able health

the test results to Evan ’ s supervisor. When Evan returned to work, he was terminated for “poor job performance,” although he had superior Assessments. In the process of fi ling a discrimination suit against his employer, Evan discovered that the information about his health status had come from this source. A lawsuit was fi led against the hospital and the nurse involved based on a breach of confi dentiality.

chapter 3 ■ Nursing Practice and the Law 41

information by health-care providers, institutions, and other entities that provide confi dential phys- ical or psychological care. For this reason, many institutions have implemented policies that aff ect employees and student affi liations. Th ese policies may result in employee termination or cancelation of agreements with outside agencies using the health-care institution.

Take the following example:

fact the client does not carry that diagnosis, could be considered a slanderous statement.

Slander and libel also refer to statements made about coworkers or other individuals whom you may encounter in both your professional and edu- cational life. Th ink before you speak and write. Sometimes what may appear to be harmless to you, such as a complaint, may contain statements that damage another person ’ s credibility personally and professionally. Consider this example:

Several nursing students who received scholar- ships from an affi liated health-care organization, composed of multiple hospitals, were working their required shift in the emergency depart- ment. Th e staff brought in a birthday cake for one of the emergency department physicians. One of the students snapped a “selfi e” with the staff and the physician and posted it on her social network page. Th e computer screen with the names and information of the clients in the emergency department at the time was clearly visible behind the group. Another staff member noticed this and immediately notifi ed the chief nursing offi cer of the hospital. Th e nursing student lost her scholarship, was terminated from her job, was required to return all monies to the organization, and was identifi ed as a “Do Not Hire” within the organization. Disciplinary actions were instituted against the staff involved in the incident. Because this organization owned all the hospitals, clinics, and physician practices within the geographic area, the student needed to attempt to gain employment in an area 50 miles from her home.

Slander and Libel Slander and libel are categorized as quasi- intentional torts. Th e term slander refers to the spoken word, whereas libel refers to the written word. Nurses rarely think of themselves as being guilty of slander or libel, but making a false verbal statement about a client ’ s condition that may result in an injury is considered slander. Making a false written statement is libel. For example, verbally stating that a client who had blood drawn for drug testing has a substance abuse problem, when in

Several nurses on a unit were having diffi culty with a nurse manager. Rather than approach the manager or follow the chain of command, they decided to send a written statement to the chief executive offi cer (CEO) of the hospital. In this letter, they embellished some of the inci- dents that occurred and took statements that the nurse manager made out of context, chang- ing the meaning of the remarks. Th e CEO called the nurse manager to the offi ce and rep- rimanded her for these events and statements that had in fact not occurred, documented the meeting, and developed an action plan that was placed in her personnel fi le. Th e nurse manager sued the nurses for slander and libel based on the premise that her personal and profes- sional reputation had been tainted. She also fi led a complaint against the hospital CEO for failure to appropriately investigate the situation, demanding a verbal and written apology.

False Imprisonment False imprisonment is confi ning an individual against his or her will by either physical (restrain- ing) or verbal (detaining) means. Th e following represent examples of false imprisonment:

■ Using restraints on individuals without the appropriate written consent or following protocols

■ Restraining mentally challenged individuals who do not represent a threat to themselves or others

■ Detaining unwilling clients in an institution when they desire to leave

■ Keeping persons who are medically cleared for discharge for an unreasonable amount of time

42 unit 1 ■ Professionalism

■ Removing a client ’ s clothing to prevent him or her from leaving the institution

■ Th reatening clients with some form of physical, emotional, or legal action if they insist on leaving

Sometimes clients are a danger to themselves and to others. Nurses need to decide on the appro- priateness of restraints as a protective measure. Nurses should always try to obtain the cooperation of the client before applying any type of restraint and follow the institutional protocols and stan- dards for restraint use ( Springer, 2015 ). Th e fi rst step is to attempt to identify a reason for the risky or threatening behavior and resolve the problem. If this fails, document the need for restraints, consult with the health-care provider, and conduct a complete assessment of the patient ’ s physical and mental status. Systematic documentation and con- tinuous assessment are of highest importance when caring for clients who have restraints. Any changes in client status must be reported and documented. Failure to follow these guidelines may result in greater harm to the client and possibly a lawsuit for the staff . Consider the following example:

To protect themselves against charges of negli- gence and false imprisonment in cases similar to this one, nurses should discuss safety needs with clients, their families, or other members of the health-care team. Careful assessment and docu- mentation of client status remain imperative and are also components of good nursing practice. Confusion, irritability, and anxiety often result from metabolic causes that need correction, not restraint.

Th ere are statutes and case laws specifi c to the admission of clients to psychiatric institutions. Most states have guidelines for emergency invol- untary hospitalization for a specifi c period of time. Involuntary admission is considered necessary when clients demonstrate a danger to themselves or others. Specifi c procedures and legal guidelines must be followed. A determination by a judge or administrative agency or certifi cation by a specifi ed number of health-care providers that a person ’ s mental health justifi es his or her detention and treatment may be required. Once admitted, these clients may not be restrained unless the guidelines established by state law and the institution ’ s policies provide for this possibility. Clients who voluntarily admit themselves to psychiatric institutions are also protected against false imprisonment. Nurses working in areas such as emergency departments, mental health facilities, and so forth, need to be cognizant of these issues and fi nd out the policies of their state and employing institution.

Assault and Battery Assault is threatening to do harm. Battery is touch- ing another person without his or her consent. Th e signifi cance of an assault lies in the threat: “If you don ’ t stop pushing that call bell, I ’ ll sedate you” is considered an assaultive statement. Battery would occur if the sedation was given when it was refused,

Mr. Harvey, an 87-year-old man, was admit- ted from home to the emergency department with severe lower abdominal pain and vomit- ing of 3 days’ duration. Before admission, he and his wife lived alone, remained active in the community, and cared for themselves without diffi culty. Physical assessment revealed severe dehydration and acute distress. Physical exam- ination revealed a ruptured appendix. A surgeon was called, and after a successful surgery, Mr. Harvey was sent to the intensive care unit for 24 hours. He was transferred to the surgi- cal fl oor awake, alert, and oriented and in stable condition. Later that night he became con- fused, irritable, and anxious. He attempted to climb out of bed and pulled out his indwelling urinary catheter. Th e nurse restrained him. Th e next day his irritability and confusion contin- ued. Mr. Harvey ’ s nurse placed him in a chair, tying and restraining his hands. When his wife came to the hospital 3 hours later, she found him in the chair, completely unresponsive. He had died of cardiopulmonary arrest. A lawsuit

of wrongful death and false imprisonment was brought against the nurse manager, the nurses caring for Mr. Harvey, and the institution. It was determined that the primary cause of Mr. Harvey ’ s behavior was hypoxemia. A vio- lation of law occurred with the failure of the nursing staff to notify the physician of the cli- ent ’ s condition and to follow the institution ’ s standard of practice on the use of restraints.

chapter 3 ■ Nursing Practice and the Law 43

even if the medical personnel deemed it necessary for the “client ’ s good.” With few exceptions, clients have the right to refuse treatment. Holding down a violent client against his or her will and inject- ing medication is considered battery. Most medical treatments, particularly surgery, would be consid- ered battery if clients failed to provide informed consent.

Standards of Practice

Avedis Donabedian, credited as the “Father of Quality Assurance,” said, “Standards are profes- sionally developed expressions of the range of acceptable variations from a norm or criterion” ( Best & Neuhauser, 2004 ). Concern for the quality of care is a major part of nursing ’ s responsibility to the public. Th erefore, the nursing profession is accountable to the consumer for the quality of its services.

One defi ning characteristic of a profession is the ability to set its own standards. Nursing standards were established as guidelines for the profession to ensure acceptable quality of care. Clear state- ments of the scope of practice including specialty nursing practice and standards of specialty practice and professional performance Help and promote continued awareness and recognition of nurses’ varied professional contributions ( Finnel, Th omas, Nehring, McLoughlin, & Bickford, 2015 ).

SBONs and professional organizations develop standards and delineate responsibilities ( Finnel et al., 2015 ). Statutes written by the government, professional organizations, and health-care insti- tutions establish standards of practice. Th e nurse practice acts of each state defi ne the boundaries of practice within those states.

Standards of practice are also used as criteria to determine whether appropriate care has been delivered. In practice, they represent the minimum acceptable level of care. Th ey take many forms. Some are written and appear as criteria of profes- sional organizations, job descriptions, and agency policies and procedures. Many may be found in textbooks and fi nd their basis in evidence-based practice ( Moff ett & Moore, 2011 ). Nurses are judged on generally accepted standards of practice for their level of education, experience, position, and specialty area ( Finnel et al., 2015 ).

Th e courts have upheld the authority of boards of nursing to regulate standards of practice. Th e

boards accomplish this through direct or dele- gated statutory language (Maloney & Harper, 2016). Th e ANA developed specifi c standards of practice for general practice areas and in several clinical areas (ANA, 2015). (See Appendix 1.) “Specialty organizations align with those broad parameters by developing and revising their own specifi c scope and standards of practice. Standards of professional practice include a description of the standard followed by multiple competency state- ments that serve as evidence for compliance with the standard” ( Maloney & Harper, 2016 , p. 327).

Institutions develop internal standards of practice. Th e standards are usually explained as a specifi c institutional policy (for example, guidelines for the appropriate administration of a specifi c chemotherapeutic agent), and the institution includes these standards in its policy and proce- dure manuals. Th e guidelines are based on current literature and research (evidence-based practice). It is the nurse ’ s responsibility to meet the institution ’ s standards of practice, whereas it is the institution ’ s responsibility to notify the health-care personnel of any changes and instruct the personnel about the changes. Institutions may accomplish this task through written memos or meetings and in-service education.

With the expansion of advanced nursing prac- tice, the need to clarify the legal distinctions and scope of practice among the varied levels of education and certifi cation has become increas- ingly important ( Feringa, DeSwardt, & Havenga, 2018 ). Patient care has become more complex and nursing skills more technologically advanced, causing some blurring of boundaries. In cer- tain high-acuity areas, nurses make independent decisions based on protocols and standards devel- oped by the institution. However, these practices remain institution-specifi c with the expecta- tion that the nurse has received the appropriate education to implement the protocols ( Feringa et al., 2018 ). Nurses need to realize that the same practices may be unacceptable in another setting.

Th ese changes in practice require nurses to familiarize themselves with the boundaries among the professional demands and the scope and stan- dards of practice within the discipline and various specialties. Th e nurse practice acts help nurses clarify their roles at the varied practice levels ( Altman, Butler, & Shern, 2016 ).

44 unit 1 ■ Professionalism

Use of Standards in Nursing Negligence and Malpractice Actions When omission of prudent care or acts committed by a nurse or those under his or her supervision cause harm to a client, standards of nursing prac- tice are among the elements used to determine whether malpractice or negligence exists. Other criteria may include but are not limited to:

■ National, state, or local (community—those used universally within the community) standards

■ Institutional policies that alter or adhere to the nursing standards of care

■ Expert opinions on the appropriate standard of care at the time

■ Available literature and research that substantiates a standard of care or changes in the standard

Patient ’ s Bill of Rights In 1973 the American Hospital Association (AHA) approved a statement called the Patient ’ s Bill of Rights. It was revised in October 1992. Patient rights were developed with the belief that hospitals and other health-care institutions and providers would support them with the goal of delivering eff ective client care. In 2003 the Patient ’ s Bill of Rights was replaced by the Patient Care Partnership. Th ese standards were derived from the ethical principle of autonomy.

In 2010, President Obama announced new regulations that included a set of protections that applied to health coverage that started in Sep- tember, 6 months after the Congress enacted the Aff ordable Care Act. Th is addition was designed to protect children and eventually all Americans who have preexisting conditions and help them obtain and keep coverage, off er a choice of health- care providers, and end the lifetime limits on the ability to receive care ( Centers for Medicare and Medicaid Services [CMS], 2010 ).

Informed Consent Informed consent is a legal document in all 50 states. It requires health-care providers to divulge the benefi ts, risks, and alternatives to a suggested treatment, nontreatment, or procedure. It allows for fully informed, rational persons to maintain involvement in their health and health- care decisions ( Hall, Prochazka, & Fink, 2012 ). “While the concept of informed consent evolved

under the theory of legal battery, it is now con- sidered under the legal domain of negligence” ( Moore, Moff et, Fider, & Moore, 2014 , p. 923).

Although the concept of consent goes as far back as ancient legal and philosophical princi- ples, the modern legal model for “simple” consent was based on the case of Schloendorff v. Society of New York Hospital in 1914. In this case, a young woman agreed to an examination of her uterus while under anesthesia, but she had not consented to surgery. Her surgeon discovered a tumor and removed her uterus. Although the New York court dismissed the patient ’ s claim for reasons that were not related to providing consent, the case gave the judge a chance to discuss and contribute to the development of the legal concept of informed consent. Th e judge noted that it was the patient ’ s “understanding” that there was only to be an examination, and that the patient ’ s understanding was crucial to determining consent. Th e New York Court of Appeals issued a decision that laid the groundwork for informed consent and instituted a patient ’ s “right to determine what shall be done with his body” ( Moore et al., 2014 ).

Without informed consent, many of the pro- cedures performed on clients in a health-care setting may be considered battery or unwarranted touching. When clients consent to treatment, they give health-care personnel the right to deliver care and perform specifi c treatments without fear of prosecution. Although physicians and other practitioners performing procedures or care are responsible for obtaining informed consent, nurses often fi nd themselves involved in the process.

It is the responsibility of the practitioner who is performing the procedure or treatment to give information to a client about the benefi ts and risks of treatment and outcomes ( Th e Joint Commission [TJC], 2016 ). Although the nurse may witness the signature of a patient or client for a procedure or surgery, the nurse should not be providing details such as the benefi ts, risks, or possible outcomes. Th e individual institution is not responsible for obtaining the informed consent unless (1) the physician or practitioner is employed by the insti- tutions, or (2) the institution was aware or should have been aware of the lack of informed consent and failed to act on this fact ( Hall, Prochazka, & Fink, 2012 ). Some institutions require the physi- cian or independent practitioner to obtain his or her own informed consent by getting the patient ’ s

chapter 3 ■ Nursing Practice and the Law 45

signature at the time the provider off ers the expla- nation for treatment.

Although some nurses believe that they only need to obtain the client ’ s signature on the informed consent document, nursing professionals have a larger responsibility in evaluating a client ’ s ability to give informed consent. Th e nurse ’ s role is to: (1) act as the patient ’ s advocate; (2) protect the patient ’ s dignity; (3) identify fears or concerns; and (4) determine the patient ’ s level of understanding and approval of the proposed care.

Every client brings a diff erent and unique response depending on his or her personality, level of education, emotions, and cognitive status. A good practice is to ask the client to restate the information off ered. Th is helps confi rm that the client has received an appropriate amount of information and understands it. Th e nurse remains obliged to report any concerns about the client ’ s understanding regarding what he or she has been told or any concerns about the client ’ s ability to make decisions.

Th e defi ning opinion on the requirements of informed consent emerged from the case of Canterbury v. Spence. In this situation, a young patient developed paralysis after spinal surgery ( Moore et al., 2014 ). Th e patient and the family asked the surgeon if the operation was serious, and he responded, “Not any more than any other operation.” Th e suit was litigated as a “failure to obtain informed consent due to battery” (p. 923); however, the court determined that this con- stituted an issue of negligence. Besides putting informed consent completely within the concept of negligence, this landmark case put forth many of the elements of informed consent we recog- nize today. Th e informed consent form should contain all the possible negative outcomes as well as the positive ones. Th e following are some criteria to help ensure that a client has given an informed consent ( Bal & Choma, 2012 ; Gupta, 2013 ):

■ A mentally competent adult has voluntarily given the consent.

■ Th e client understands exactly as to what he or she is consenting.

■ Th e consent includes the risks involved in the procedure, alternative treatments that may be available, and the possible result if the treatment is refused.

■ Th e consent is written. ■ A minor ’ s parent or guardian needs to give

consent for treatment.

Ideally, a nurse should be present when the health- care provider who is performing the treatment, surgery, or procedure is explaining benefi ts and risks to the client.

To give informed consent, the client must receive complete information and understand the risks and benefi ts. Clients have the right to refuse treatment, and nurses must respect that right. If a client refuses the recommended treatment plan, he or she needs to be fully informed of the possi- ble consequences of the decision in a nonforceful, noncoercive manner. Th is caveat remains excep- tionally important; if clients consent because they feel coerced and the outcome is less than favorable, all parties involved in obtaining the consent may fi nd themselves at risk ( Hall et al., 2012 ).

Implied consent occurs when consent is assumed ( Moore et al., 2014 ). Th is often occurs in emergency situations when an individual is unable to give consent. State laws support the right of health-care providers to act in an emergency without the expressed consent of the patient. It is also important to note that complications of that procedure may be legally defensible if the providers acted in a reasonable, prudent manner. A recent civil case, Futral v. Webb, supported this. In this lawsuit, a patient presented in shock and with altered mental status. Th e emergency depart- ment provider placed a subclavian line for fl uids and caused a hemothorax. A chest tube was then inserted; however, the patient became bradycardic, arrested, and died. Th e patient ’ s family sued the provider; however, the jury ruled in favor of the provider and the hospital based on the fact that the complication was a known and accepted risk of the procedure. Th ey also asserted that the pro- vider acted in the best interests of the patient when unable to receive expressed consent ( Moore et al., 2014 ).

Nurses may fi nd themselves involved in emer- gent situations where consent may be implied. Trauma centers often have protocols in place that address provider roles and actions in order to avoid legal actions. In these cases, follow the health-care institution policies, carefully document the client ’ s status, attempt to reach signifi cant others, and identify pertinent assessment data.

46 unit 1 ■ Professionalism

Staying Out of Court

Prevention Unfortunately, the public ’ s trust in the health- care industry and the medical profession has declined during recent years. Consumers are better informed and more assertive in their approach regarding care. Th ey demand safe and eff ective care that promotes positive outcomes. If clients and their families perceive that the provider exhib- its an impersonal attitude and uncaring behaviors, they are more likely to sue for what they believe are errors in treatment.

Th e same applies to nurses. If nurses demon- strate a caring attitude and interest toward their clients and families, a relationship develops. Indi- viduals rarely initiate lawsuits against those they view as “caring friends.” Demonstrating care and concern and making clients and families aware of choices and explaining situations helps decrease liability. Nurses who involve clients and families in care and decisions about care reduce the likelihood of a lawsuit. Tips to prevent legal problems are listed in Box 3-1 .

All health-care personnel remain accountable for their own actions and adherence to accepted standards of care. Most negligence and malpractice suits arise from the violation of the accepted stan- dards of practice and the policies of the employing institution. Common causes of negligence are listed in Table 3-1 . Expert witnesses are called to cite the accepted standards and Help attorneys on

both sides in formulating legal strategies pertain- ing to those standards.

Appropriate Documentation

Th e adage “not documented, not done” holds true in nursing. According to the law, if something is not documented, then the responsible party did not do whatever needed to be done. If a nurse did not “do” something, he or she will be left open to negligence or malpractice charges.

Nursing documentation needs to be legally credible. Th e move to computerized charting, known by various names, has decreased some con- cerns but added others. Catalano ( 2014 ) provided several tips regarding electronic documentation. Nurses need to be cognizant that in the electronic record, everything documented exists and does not disappear. In other words, nurses cannot simply rip up the paper and start a new sheet or new form. Many systems require wrong information to be deleted, and this leaves an “electronic footprint.” It also requires a valid explanation for the deletion and insertion. All applicable spaces and areas need to be completed, and nurses must avoid copying and pasting at all costs. Although some nurses

box 3-1

Tips for Avoiding Legal Problems

• Keep yourself informed regarding new research related to your area of practice.

• Insist that the health-care institution keep personnel apprised of all changes in policies and procedures and in the management of new technological equipment.

• Always follow the standards of care or practice for the institution.

• Delegate tasks and procedures only to appropriate personnel.

• Identify clients at risk for problems, such as falls or the development of decubiti.

• Establish and maintain a safe environment. • Document precisely and carefully. • Write detailed incident reports, and fi le them with the

appropriate personnel or department. • Recognize certain client behaviors that may indicate

the possibility of a lawsuit.

table 3-1

Common Causes of Negligence

Problem Prevention Client falls Identify clients at risk.

Place notices about fall precautions. Follow institutional policies on the use of restraints. Always be sure beds are in their lowest positions. Use side rails appropriately.

Equipment injuries

Check thermostats and temperature in equipment used for heat or cold application. Check wiring on all electrical equipment.

Failure to monitor

Observe IV infusion sites as directed by institutional policy. Obtain and record vital signs, urinary output, cardiac status, and so on, as directed by institutional policy and more often if client condition dictates. Check pertinent laboratory values.

Failure to communicate

Report pertinent changes in client status. Document changes accurately. Document communication with appropriate source.

Medication errors

Follow the Seven Rights. Monitor client responses. Check client medications for multiple drugs for the same actions.

chapter 3 ■ Nursing Practice and the Law 47

seem to feel this saves time, it also opens up a new area for documentation errors if a piece of infor- mation is incorrect or deleted.

Even when nurses are using an electronic method for documentation, some of the “old rules” still apply:

■ Remember to only use approved abbreviations. ■ Document at the time care was provided. ■ Keep documentation objective. ■ Ensure appropriateness (document only what

could be discussed comfortably in a public setting).

■ Always use the barcodes on both clients and medications.

■ Avoid shortcuts on documentation.

Common Actions Leading to Malpractice Suits ■ Failure to assess a client appropriately ■ Failure to report changes in client status to the

appropriate personnel ■ Failure to document in the patient record ■ Falsifying documentation or attempting to alter

the patient record ■ Failure to report a coworker ’ s negligence or

poor practice ■ Failure to provide appropriate education to

patients and families ■ Violation of an internal or external standard of

practice

In the case of Tovar v. Methodist Healthcare ( 2005 ), a 75-year-old female came to the emergency department reporting a headache and weakness in her right arm. Although the physician wrote an order for admission to the neurological care unit, 3 hours passed before the patient was transferred. After the patient was admitted to the unit, nurses called a physician regarding the client ’ s status; however, it took 90 minutes for another physi- cian to return the call. Th ree hours later the nurses called to report a change in the patient ’ s neuro- logical status. A STAT computerized tomography scan was ordered, which revealed a massive brain hemorrhage. Th e courts established the following based on the standard of care:

Nursing personnel provided poor documentation of the clinical status of Ms. Rodriguez between 5 p.m.

and 9 p.m. Despite the patient ’ s obvious deteriora-

tion at that time, they meekly accepted inadequate

responses of Dr. Garrison and Dr. Osonma with no

further calls to physicians until 12:30 a.m. when

the patient was in extremis. Th e appropriate stan-

dard of care for nursing personnel treating a patient

with acute neurological process is to promptly and

expeditiously transfer the patient to the appropriate

setting and carefully inform the treating physi-

cians of changes in the patient ’ s clinical status so

that appropriate care can be rendered. Th e nursing

personnel failed to perform these critical functions

in their management of Ms. Rodriguez, thereby

breaching the standard of care. ( Tovar v. Method- ist Healthcare, 2005 )

Th e nurses were also cited for:

1. Delay in transferring the patient to the neurological care unit

2. Failure to advocate for the patient

If a Problem Arises When served with a summons or complaint, people often panic, allowing fear to overcome reason. First, simply answer the complaint. Failure to do this may result in a default judgment, causing greater distress and diffi culties.

Second, individuals may take steps to protect themselves if named in a lawsuit. If a nurse carries malpractice, notify the carrier immediately. Legal representation can be obtained to protect personal property. Never sign any documents without con- sulting the malpractice insurance carrier or legal representative.

Institutions usually have lawyers to defend themselves and their employees. Whether or not you are personally insured, contact the legal depart- ment of the institution where the act occurred. Maintain a fi le of all papers, proceedings, meetings, e-mails, texts, and phone conversations about the case. Do not discuss the case with anyone outside of the appropriate individuals, and do not with- hold any information from your attorneys, even if the information may be harmful to you. Con- cealing information usually causes more damage. Let the attorneys and the insurance company help decide how to handle the diffi cult situation. Th ey are in charge of damage control.

Sometimes, nurses believe they are not being adequately protected or represented by the attor- neys from their employing institution. If this happens, consider hiring a personal attorney who is experienced in malpractice law. Th is information

48 unit 1 ■ Professionalism

can be obtained through either the state bar asso- ciation or the local trial lawyers association.

Anyone has a right to sue; however, that does not always mean a case exists. Many negligence and malpractice cases fi nd in favor of the health- care providers, not the client nor the client ’ s family. Consider the case of Grant v. Pacifi c Medical Center, Inc. ( 2014 ). In this case, the plaintiff failed to prove negligence and malpractice and then fi led an appeal of the dismissal of the original verdict in the malpractice case. Th e Supreme Court of the State of Washington upheld the original verdict established by the Court of Appeals. See the fol- lowing for the summary of this case:

Ms. Grant failed to produce any expert medical testimony to the trial court to establish the stan-

dard of care, a violation of the standard of care or

proximate causation; and equally failed to raise

any legitimate issues in this regard to the Court of

Appeals. (p. 8)

Professional Liability Insurance

We live in a litigious society. Although a variety of opinions exist on this issue, in today ’ s world nurses need to consider obtaining personal liability insurance ( Pohlman, 2015 ). Although physicians get sued more than nurses, health-care institu- tions realize the contributions of all members of the health-care team. A nurse can be found liable under the specifi c circumstances mentioned during this chapter. Even in a case of a frivolous suit, where the patient fails to incur damages but hopes to collect on a settlement, the nurse faces expenses ( Pohlman, 2015 ).

If a nurse is charged with malpractice and found guilty, the employing institution holds the right to sue the nurse to reclaim damages. When a nurse has his or her own liability insurance, the company provides legal counsel. Th e company may also negotiate with another company on the nurse ’ s behalf. Many liability policies also cover assault, violations of HIPAA, libel, slander, and property damage.

End-of-Life Decisions and the Law

When a heart ceases to beat, a client is in a state of cardiac arrest. In health-care institutions and in the community, it is common to initiate cardiopul- monary resuscitation (CPR) when this occurs. In health-care institutions, an elaborate mechanism is put into action when a patient “codes.” Much controversy exists concerning when these mecha- nisms should be used and whether individuals who have no chance of regaining full viability should be resuscitated.

Do Not Resuscitate Orders A do not resuscitate order (DNR) is a specifi c directive to health-care personnel not to initi- ate CPR measures. In the past, only physicians could write DNR orders; however, in many states, nurse practitioners and physician Helpants may also write a DNR order ( Hayes, Zive, Ferrell, &

Patricia A. Grant, a veteran with multiple health concerns, received health care through the Department of Defense Health Care Program, delivered by the Family Health Plan at Pacifi c Medical Centers, Inc. Th e allegations in the petitioner ’ s complaint selectively refer to care received in 2009 by Linda Oswald, MD, a board-certifi ed family practice physician. Ms. Grant ’ s medical history includes morbid obesity, mental illness, hypertension, plantar fasciitis, and diabetes. Ms. Grant also under- went multiple prior surgeries, including a Roux Y gastric bypass procedure performed at Valley Medical Center in June 2009. Th ree months later Ms. Grant was referred to a board-certifi ed gastroenterologist for a complaint of nausea, vomiting, and other gastrointestinal system issues. Ms. Grant ’ s providers at the health-care institution referred her to multiple, board- certifi ed specialists for her continuing medical issues of nausea and vomiting.

At both the trial court level and in her ensuing appeal, Ms. Grant failed to make a “showing suffi cient to establish the existence of the key element of her case—the applica- ble standard of care in Washington and that a breach of this standard occurred causing her injury. She bore the burden of proof and her failure to produce medical evidence in support of her allegations was fatal to her case and summary judgment was appropriate” (p. 7).

In this case the Court of Appeals based its deci- sion on existing well-established law and stated the following:

chapter 3 ■ Nursing Practice and the Law 49

Toll, 2017 ). Th erefore, it is imperative that a nurse check with the institutional policy to ensure that this is an acceptable practice. Th ese types of orders are only written after the provider has consulted with the client or his or her family. Clients have the right to request a DNR order; however, they may not fully understand the ramifi cations of their request.

Although New York State has one of the most complete laws regarding DNR orders for acute and long-term care facilities, all states have legisla- tion regarding this request. In 2007, the American Bar Association (ABA), in collaboration with the Department of Health and Human Services (DHSS), developed a document addressing the overall legal and policy issues regarding DNR

requests and orders ( Sabatino, 2007 ). Th is docu- ment outlined the overall existence of common law cases and policies that support a patient ’ s right to self-determination. Th is action has been sup- ported by the ANA (1992, 2005). It is important for the nurse to familiarize himself or herself with the policies and procedures of the employing insti- tution. Th e nurse ’ s role in DNR orders are listed in Box 3-2 .

Advance Directives Th e legal dilemmas that may arise in relation to DNR orders often require court decisions. For this reason, in 1990, Senator John Danforth of Missouri and Senator Daniel Moynihan of New York introduced the PSDA to address questions

box 3-2

The Nurse ’ s Role in DNR Orders The American Nurses Association recommends that: • Clinical nurses actively participate in timely and

frequent discussions on changing goals of care and initiate DNR/AND discussions with patients and their families and signifi cant others.

• Clinical nurses ensure that DNR orders are clearly documented, reviewed, and updated periodically to refl ect changes in the patient ’ s condition (Joint Commission, 2010).

• Nurse administrators ensure support for the clinical nurse to initiate DNR discussions.

• Nursing home directors and hospital nursing executives develop mechanisms whereby the AND form accompanies all inter-organizational transfers.

• Nurse administrators have an obligation to assure palliative care support for all patients.

• Nurse educators teach that there should be no implied or actual withdrawal of other types of care for patients with DNR orders. DNR does not mean “do not treat.” Attention to language is paramount, and euphemisms such as “doing everything,” “doing nothing,” or “withdrawing care or treatment,” to indicate the absence or presence of a DNR order should be strictly avoided.

• Nurse educators develop and provide specialized education for nurses, physicians, and other members of the interdisciplinary health care team related to DNR, including conversations on moving away from DNR and toward AND language.

• Nurse researchers explore all facets of the DNR process to build a foundation for evidence-based practice. ANA Position Statement 10 Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions

• All nurses ensure that whenever possible, the DNR decision is a subject of explicit discussion between the

health care team, patient, and family (or designated surrogate), and that actions taken are in accordance with the patient’s wishes.

• All nurses facilitate and participate in interdisciplinary mechanisms for the resolution of disputes between patients, families, and clinicians’ DNR orders (Cantor, et al., 2003).

• All nurses actively participate in developing DNR policies within the institutions where they work. Specifi cally, policies should address, consider, or clarify the following: ○ Guidance to health care professionals who

have evidence that a patient does not want CPR attempted but for whom a DNR order has not been written

○ Required documentation to accompany the DNR order, such as a progress note in the medical record indicating how the decision was made

○ The role of various health care practitioners in communicating with patients and families about DNR orders

○ Effective communication of DNR orders when transferring patients within or between facilities

○ Effective communication of DNR orders among staff that protects against patient stigmatization or confi dentiality breaches

○ Guidance to practitioners on specifi c circumstances that may require reconsideration of the DNR order (e.g., patients undergoing surgery or invasive procedures)

○ The needs of special populations (e.g., pediatrics and geriatrics).

ANA Position Statement 10 Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions

Source: American Nurses Association. (2012). Position statement on nursing care and do not resuscitate decisions. Washington, DC: ANA.

50 unit 1 ■ Professionalism

regarding life-sustaining treatment. Th e act was created to allow people the opportunity to make decisions about treatment in advance of a time when they might become unable to participate in the decision-making process. Th rough this mecha- nism, families can be spared the burden of having to decide what the family member would have wanted.

Federal law mandates that health-care institu- tions that receive federal monies (from Medicare or Medicaid) inform clients of their right to create advance directives (H.R. 5067, 1995). Th e PSDA (S.R. 13566) provides guidelines for developing advance directives concerning what will be done for individuals if they are no longer able to par- ticipate actively in making decisions about care options. More information regarding the PSDA may be found at www.congress.gov .

Living Will and Durable Power of Attorney for Health Care (Health-Care Surrogate)

Th e two most common forms of advance direc- tives are living wills and durable power of attorney. Living wills and other advance directives describe individual preferences regarding treatment in the event of a serious accident or illness. Th ese legal documents indicate an individual ’ s wishes regard- ing care decisions ( Sabatino, 2010 ). A living will is a legally executed document that states an indi- vidual ’ s wishes regarding the use of life-prolonging medical treatment in the event that he or she is no longer competent to make informed treatment decisions on his or her own behalf ( Sabatino, 2010 ). A condition is considered terminal when to a reasonable degree of medical certainty there is little likelihood of recovery or the condition is expected to cause death. A terminal condition may also refer to a severe neurological entity, a persistent vegetative state characterized by a permanent and irreversible condition of unconsciousness in which there is (1) absence of voluntary action or cogni- tive behavior of any kind and (2) an inability to communicate or interact purposefully with the environment ( Shea & Bayne, 2010 ).

Another function of the advance directive is to designate a health-care surrogate. Th e role of the health-care surrogate is to make the client ’ s wishes known to medical and nursing personnel. Chosen by the client, the health-care surrogate is usually a family member or close friend. Imperative in the designation of a health-care surrogate is a clear

understanding of the client ’ s wishes should the need arise.

In some situations, clients are unable to express themselves adequately or competently, although they may not be considered “terminally ill.” For example, clients who have been diagnosed with a cognitive impairment such as Alzheimer ’ s disease or other forms of dementia cannot communicate their wishes; clients under anesthesia are tempo- rarily unable to communicate; and the condition of a comatose client fails to allow for expression of health-care wishes. In these situations, the des- ignated health-care surrogate can make treatment decisions on behalf of the client. However, when a client regains the ability to make his or her deci- sions and is capable of expressing them eff ectively, he or she resumes control of all decision making pertaining to medical treatment. Nurses and other providers may be held accountable when they go against a client ’ s wishes regarding DNR orders.

In the case of Wendland v. Sparks ( Reagan, 1998 ), the physician and nurses were sued for not “initiating CPR.” In this case, the client had been hospitalized for more than 2 months for a lung disease and multiple myeloma. Although improving at the time, during the hospitalization the client experienced three cardiac arrests. Even after this she had not requested a DNR order, nor had her family. After one of the arrests the client ’ s husband stated to the physician that he wanted his wife to be placed on life support if necessary. Th e client suff ered a fourth cardiac arrest. One nurse went to obtain the crash cart while another con- tacted the physician who happened to be in the area. Th e physician checked the client ’ s heart rate, respirations, and pupillary reaction and stated, “I just cannot do this to her.” She ordered the nurses to stop resuscitation, and the physician pro- nounced the client. Th e nurses stated had they not been given a direct order, they would have contin- ued their attempts at resuscitation. Th e court ruled in favor of the family, indicating that the physician exercised faulty judgment. Th e nurses were cleared as they followed a physician order.

Nursing Implications Th e PSDA does not specify who should discuss treatment decisions or advance directives with clients. Because directives are often implemented on care units, nurses must be knowledgeable regard- ing living wills, advance directives, and health-care

chapter 3 ■ Nursing Practice and the Law 51

Study Questions

1. How do federal laws, court decisions, and SBONs aff ect nursing practice? Give an example of each.

2. Obtain a copy of the nurse practice act in your state. What are some of the penalties for violation of the rules and regulations?

3. Review the minutes or documents of a state board meeting. What were the most common issues for nurses to be called before the board of nursing? What were the resulting disciplinary actions?

4. Th e next time you are on your clinical unit, look at the nursing documentation done by several diff erent staff members. Do you believe it is adequate? Explain your rationale.

5. How does your clinical institution handle medication errors?

6. If a nurse is found to be less than profi cient in the delivery of safe care, how should the nurse manager remedy the situation?

7. Discuss where appropriate standards of care may be found. Explain whether each is an example of an internal or external standard of care.

8. Explain the importance of federal agencies in setting standards of care in health-care institutions.

9. What is the diff erence between consent and informed consent?

10. Look at the forms for advance directives and DNR policies in your institution. Do they follow the guidelines of the PSDA?

11. What are the most common errors nurses commit that lead to negligence or malpractice?

12. What impact would a law that prevents mandatory overtime have on nurses, nursing care, and the health-care industry? Find out if your state has mandatory overtime legislation.

surrogates. Th ey need to be prepared to answer questions that clients may ask about the directives and forms used by the health-care institution.

Th e responsibility for creating an awareness of individual rights often falls on nurses because they act as client advocates. Th e responsibility for edu- cating the professional staff about policies resides with the health-care institution. Nurses who are unsure of the existing policies and procedures of the institution should contact the appropriate department for clarifi cation.

Conclusion

Nurses need to understand the legalities involved in the delivery of safe and eff ective health care that

promotes positive outcomes. It is important to be familiar with the standards of care established within your institution and the rules and regula- tions that govern nursing practice within your state because these are the standards to which you will be held accountable. Health-care consumers have a right to expect quality care and that their health information will remain confi dential. Caring for clients safely and avoiding legal diffi culties requires nurses to adhere to standards of care and their scope of practice and carefully document changes in client conditions.

52 unit 1 ■ Professionalism

NCLEX®-Style Review Questions

1. Which common practice puts the nurse at liability for invasion of patient privacy? 1. During care, the nurse reveals information about the patient to those in the room. 2. Th e nurse releases information about the patient to nursing students who will be caring for

the patient the next day. 3. Th e nurse conducts a patient care session about a patient whose care is diffi cult and

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