A. Total quality management/continuous quality improvement
1. Standards of nursing practice
Standards of practice provide objective measurement guidelines for the provision of care in order to evaluate care.
a. ANA Standards of Nursing Practice
ANA Standards of Professional Performance
Quality of care and effectiveness is systematically evaluated - participate in quality activities, practice changes as a result of quality activities
Performance appraisal of ones own practice to professional practice standards - obtains feedback on ones own practice
Education is maintained current in knowledge and competencies - ongoing educational activity participation
Collegiality
Ethics are considered in the provision of care - Codes of Ethics have been published by various organizations to assist practitioners in ethical provision of care
Collaboration
Research findings are used in practice - research findings are used to plan the care and interventions
Resource utilization
ANA Standards of Care
Assessment
Nursing Diagnosis
Planning
Implementation
b. Specialty organization practice standards
c. Other standards (for example: health care agencies, professional literature)
2. Mechanisms for quality assurance/risk management
a. Outcome achievement (critical pathways)
b. Peer review
c. Record audit
d. Certification of nurses
e. Documentation
f. Utilization review
g. Risk management
h. Research utilization
i. Consumer involvement
B. Ethical aspects of nursing practice
Terms
Autonomy is one of the basic concepts in ethics, with autonomy expressed in ethics as the basic view that the individual has the right to independence, self-determination and self-reliance.
Beneficence
Justice
Fidelity
Accountability
Responsibility
Confidentiality
Veracity
1. Values clarification
a. Personal values
The individual values held by a person influence the interpretation of information especially on conflicting or confusing material such as an ethical dilemmas.
Values are personal beliefs held by individuals concerning the worth of ideas, attitudes, customs, and objects that set the standard for behavior and actions.
Values clarification is a process of self examination of currently held values and the discovery of alternative values, with the overall increase in the understanding of how values affect behavior.
b. Codes of ethics
Most reflect similar principle including responsibility, accountability, advocacy, confidentiality, and veracity
(1) ANA Code for Nurses
1. The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2. The nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.
3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.
4. The nurse assumes responsibility and accountability for individual nursing judgments and actions.
5. The nurse maintains competence in nursing.
6. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others.
7. The nurse participates in activities that contribute to the ongoing development of the profession's body of knowledge.
8. The nurse participates in the profession's efforts to implement and improve standards of nursing.
9. The nurse participates in the profession's effort to establish and maintain conditions of employment conductive to high quality nursing care.
10. The nurse participates in the profession's effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.
11. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public
American Nurses Association: Code for nurses with interpretive statements, Kansas City, Mo., 1985, The Association.
(2) ICN Code for Nurses (1973)
The ICN Code of Ethics for Nurses
An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2000.
Preamble
Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal.
Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, nationality, politics, race or social status.
Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups.
THE CODE
The ICN Code of Ethics for Nurses has four principal elements that outline the standards
of ethical conduct.
Elements of the Code
1. Nurses and people
The nurse�s primary professional responsibility is to people requiring nursing care.
In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.
The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment.
The nurse holds in confidence personal information and uses judgment in sharing this information.
The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.
The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction.
2. Nurses and practice
The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning.
The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
The nurse uses judgment regarding individual competence when accepting and delegating responsibility.
The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.
The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.
3. Nurses and the profession
The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education.
The nurse is active in developing a core of research-based professional knowledge.
The nurse, acting through the professional organization, participates in creating and maintaining equitable social and economic working conditions in nursing.
4. Nurses and co-workers
The nurse sustains a co-operative relationship with co-workers in nursing and other fields.
The nurse takes appropriate action to safeguard individuals when their care is endangered by a co-worker or any other person.
c. ANA Social Policy Statement
2. Rights and responsibility in health care
a. Consumers' rights (e.g., the American Hospital Association's [AHA] Patient's Bill of Rights, informed consent, living wills)
The Patient Self-Determination Act (PSDA), which became law in 1980, requires that the patient be provided with information concerning their rights to have written documentation established to direct their care in the event of their becoming incapacitated. When formulated correctly, this allows the patient involvement in decisions about their health care for treatments preserving life.
b. Nurse's responsibilities (e.g., personal, professional, patient advocacy)
3. Models for ethical decision making (e.g., Aroskar, Curtin, Thompson and Thompson)
True ethical dilemmas are rare because with adequate information, adequate time and clear guidelines for actions most ethical dilemmas will be eliminate.
Ethical dilemmas can be resolved through a stepped process:
Confirm ethical dilemma: review scientific data, literature and legal issues to confirm ethical dilemma; gather and list facts of the ethical dilemma
Determine who is involved: identify the individuals involved and your role
Define your ethical position and the conflict that exists.
Identify as many alternative methods of resolution or solutions.
Select a decision, act upon it, and evaluate the result.
Thompson and Thompson
Thompson J. Thompson H: Bioethical Decision Making for Nurses. Norwalk, CT: Appleton-Century-Crofts, 1985, pp. 89-208
Aroskar
Davis A, Aroskar M: Ethical Dilemmas and Nursing Practice. New York: Appleton-Century-Crofts, 1978.
Described theories on ethical decision making
Egoism - decision is right because the provider, nurse or physician, desires that decision
deontology - right and wrong considered from moral perspective - act deontology considers providers moral views - Rule deontology considers rules for standards, often from religious beliefs.
Utilitarianism - greatest good for the most number of people, or least harm to greatest number of people
Curtin
Curtin L: Human problems: Human beings. Nurs Mgt 25:38, May 1994
Advanced three levels of decision making
1. immediate level - no time for reflection
2. intermediate level - some time available for reflection and explanation
3. deliberate level - enough time to consult and think with rational decision making thereafter.
Most ethical decisions are of the deliberate level
Rapid Approach to Emergency Ethical Problems
Iserson K et al: Ethics in emergency medicine, ed. 2, Tucson, Ariz., 1995, Galen Press.
1. Ask - is this a situation where I have a rule, yes then follow the rule,
2. No, then ask - is there an option to buy time, yes then take that option,
3. No, then use three tests to make decision:
1. Test 1 - impartiality - reverse roles with the patient and ask if that would be acceptable to you
2. Test 2 - Universal ability - would you be able to take the same action in all similar circumstances
3. Test 3 - Interpersonal Justifiability - can you provide good reasons to justify and defend actions
4. Ethical issues in nursing practice (e.g., informed consent, code/no code decisions, abortion, organ transplants, privacy and confidentiality, genetic engineering, euthanasia, right to die)
informed consent - the sharing of knowledge about the clinical findings and treatment options and plans in order that the individual can participate fully in the decisions regarding personal health
Advanced directives/Quality of Life
code/no code decisions
right to die
euthanasia
abortion regardless of personal views, the nurse is responsible for patient care, and therefore can not allow personal beliefs to interfere. The nurse may chose to participate or not participate based upon their personal beliefs; however, they must guard against non intervention actions.
organ transplants
privacy and confidentiality
genetic engineering
5. Personal and professional accountability
a. Ethical committees and institutional review boards
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in 1991 started requiring and in 1993 mandated HCOs to have "a mechanism for the consideration of ethical issues arising in the care of patients and to provide education to caregivers and patients on ethical issues in health care."
Institutions may also have nursing ethic committees (NECs) that deal more specifically with ethical elements in nursing care.
b. Application of the ANA Code for Nurses in practice
A code of ethics usually elaborates greater principles than those that are expressed in the law. Violations of a code, thus, may also be a legal violation and therefore may find resolution through this method although additional complaints may be made to the respective nursing association. As well, since the code exceeds that law, it requires a higher standard and may have a greater scope to act on a problem.
c. Whistle-blowing (reporting illegal and unethical conduct)
C. Legal liability affecting nursing practice
1. Types of laws
a. Civil v. criminal
b. Statutory v. common and case law
2. Civil law
a. Torts
(1) Slander-libel
(2) Invasion of privacy
(3) False imprisonment
(4) Negligence-malpractice
(a) Components of a negligent act
(b) Comparative v. contributory negligence
b. Contracts
(1) Elements of a valid contract
(2) Rights and responsibilities of the nurse in a contractual situation
c. Legal documents (e.g., wills, consent forms, health care records)
3. Criminal law
a. Assault and battery
b. Criminal negligence
4. Statutory law
a. Licensure
(1) Purpose
(2) Legal source - nurse practice acts
(3) Implementation
(a) Current requirements
(b) Licensure by endorsement
(c) Grounds for revocation
(d) Role of state boards for nursing
(4) Developments affecting licensure legislation
(a) 1965 ANA position paper
(b) 1985 ANA position paper
(c) Mandatory continuing education as a condition for continuing licensure
(d) Sunset laws
(e) Institutional licensure
b. Federal statues (e.g., controlled substance acts, environmental acts, Privacy Act of 1974, Freedom of Information Acts)
c. Nurse's responsibility
(1) Good Samaritan laws
(2) Reporting requirements related to the abuse of children and adults
(3) Reporting injuries resulting from weapons
D. Educational aspects of nursing practice
1. Academic preparation of nurses
a. Doctoral degree
b. Master's degree
c. Baccalaureate degree
d. Associate degree
The greatest number of programs are in the Associate degree category of nursing education. This two year program is considered comprehensive and complete providing half the program with general science and related education, and the other half theoretical and clinical nursing.
e. Diploma
Diploma or hospital based nursing education had been the primary educational method; however, they have been reduced considerably by the increase in associate degree programs, with many establishing relationships with local community colleges and now becoming associate degree programs. The number of diploma nurses working is still considerable, although many have increased their education, partly accounting for the drop.
f. Practical/vocational certificate
2. Alternative educational programs (e.g., assessment programs, second-step programs, articulation programs)
3. Credentialing (e.g., ANA certification, other specialty groups)
ANA established a certification process, and established a separately incorporated institution, the American Nurses Credentialing Center (ANCC), to provide certification, accreditation and recognition. Over 24 practice areas have certification examinations.
American Association of Critical Care Nursing, through the AACN Certification Corporation, provides Critical Care RN (CCRN) certification and recertification in adult, pediatric and adult critical care.
American College of Nurse Midwives (ACNW), through the ACNW Certification Council, Inc., provides certification for nurse midwives (CNM).
Emergency Nurses' Association, provides certification for Emergency nurses, (CEN), and for flight RNs (CFRN).
Hospice Nurse Association provides certification for RNs in Hospices (CRNH).
National Council of State Boards of Nursing (NCSBN) develops the National Council Licensure Exaninations for Registered Nurses (NCLEX-RN), and Practical Nurses (NCLEX-PN).
4. Continuing education
Continuing education (CE) programs are short formal organized educational programs that help maintain currency for nurses. Initially credited by ANA, the ANCC now awards CE credits for programs.
In-service education programs are usually institutionally based instruction to confirm or introduce new skills, and may or may not be eligible for CE credits.
5. Accreditation of academic programs (e.g., regional, state, NLN)
National Leauge for Nursing (NLN) - Division of Accreditation under the name National Nursing Accrediting Service provides voluntary (paid by the nusing program being accredited) national peer evaluation accretitation. Recommendations for improvements are made, and there is no guarentee that the program will be accredited. A listing of accredited programs is produced annual. Over fifteenhundred programs were accredetid by 1994, with over 75% of the basic programs accredited. NLN id recognised by the US Dept. Of Education and as such funds under the Nurse Traing Act of 1964, and admendments following later, are made only to NLN accredited programs.