Professional Responsibilities PDF

CHAPTER 3 Online Video: Client Rights REFUSAL OF TREATMENT CHAPTER 3 Professional The Pa...

CHAPTER 3 Online Video: Client Rights REFUSAL OF TREATMENT CHAPTER 3 Professional The Patient Self‑Determination Act (PSDA) stipulates that Responsibilities on admission to a health care facility, all clients must be informed of their right to accept or refuse care. Competent adults have the right to refuse treatment, including the right to leave a health care facility without a prescription Professional responsibilities are the obligations for discharge from the provider. If the client refuses a treatment or procedure, the that nurses have to their clients. To meet their client is asked to sign a document indicating that professional responsibilities, nurses must be they understand the risk involved with refusing the treatment or procedure, and that they have chosen to knowledgeable in the following areas: client refuse it. rights, advocacy, informed consent, advance When a client decides to leave the facility without a prescription for discharge, the nurse notifies the directives, confidentiality and information provider and discusses with the client the potential security, information technology, legal practice, risks associated with leaving the facility prior to discharge. disruptive behavior, and ethical practice. The nurse carefully documents the information that was provided to the client and that notification of the provider occurred. The client should be informed of Client rights the following. ◯ Possible complications that could occur Client rights are the legal guarantees that clients have without treatment with regard to their health care. ◯ Possibility of permanent physical or mental ◯ Clients using the services of a health care institution impairment or disability retain their rights as individuals and citizens of the ◯ Possibility of other complications that could United States. The American Hospital Association lead to death (AHA) identifies client rights in health care settings in The client is asked to sign an Against Medical the Patient Care Partnership (www.aha.org). Advice form. ◯ Residents in nursing facilities that participate If the client refuses to sign the form, this is also in Medicare programs similarly retain resident documented by the nurse. rights under statutes that govern the operation of these facilities. Nurses are accountable for protecting the rights of clients. Situations that require particular attention Advocacy include informed consent, refusal of treatment, advance Advocacy refers to nurses’ role in supporting clients by directives, confidentiality, and information security. ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care. NURSING ROLE IN CLIENT RIGHTS Advocacy is one of the most important roles of the nurse, especially when clients are unable to speak or act Nurses must ensure that clients understand their rights. for themselves. Nurses also must protect clients’ rights during As an advocate, the nurse ensures that the client has nursing care. the information they need to make decisions about Regardless of the client’s age, nursing needs, or the health care. setting in which care is provided, the basic tenants are Nurses must act as advocates even when they disagree the same. Each client has the right to the following. with clients’ decisions. ◯ Be informed about all aspects of care and take an The complex health care system puts clients in a active role in the decision‑making process. vulnerable position. Nurses are clients’ voice when the ◯ Accept, refuse, or request modification to the system is not acting in their best interest. plan of care. The nursing profession also has a responsibility to ◯ Receive care that is delivered by competent support and advocate for legislation that promotes individuals who treat the client with respect. public policies that protect clients as consumers and create a safe environment for their care. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 35  Online Video: Client Advocacy NURSING ROLE IN ADVOCACY Informed consent As advocates, nurses must ensure that clients are Informed consent is a legal process by which a client informed of their rights and have adequate information has given written permission for a procedure or on which to base health care decisions. treatment to be performed. Consent is considered to be Nurses must be careful to assist clients with making informed when the client has been provided with and health care decisions and not direct or control understands the following. their decisions. ◯ Reason the treatment or procedure is needed Nurses mediate on the client’s behalf when the actions ◯ How the treatment or procedure will benefit the client of others are not in the client’s best interest or changes ◯ Risks involved if the client chooses to receive the need to be made in the plan of care. treatment or procedure Situations in which nurses might need to advocate for ◯ Other options to treat the problem, including the clients or assist them to advocate for themselves include option of not treating the problem the following. ◯ Risk involved if the client chooses no treatment ◯ End‑of‑life decisions The nurse’s role in the informed consent process is to ◯ Access to health care witness the client’s signature on the informed consent ◯ Protection of client privacy form and to ensure that informed consent has been ◯ Informed consent appropriately obtained. ◯ Substandard practice The nurse should seek the assistance of an interpreter if Nurses are accountable for their actions even if they are the client does not speak and understand the language carrying out a provider’s prescription. It is the nurse’s used by the provider. responsibility to question a prescription if it could harm a client (incorrect medication dosage, potential adverse interaction with another prescribed medication, contraindication due to an allergy or medical history). INFORMED CONSENT GUIDELINES Consent is required for all care given in a health care facility. For most aspects of nursing care, implied consent ESSENTIAL COMPONENTS OF ADVOCACY is adequate. The client provides implied consent when SKILLS they comply with the instructions provided by the nurse. Risk‑taking For example, the nurse is preparing to administer a TB Vision skin test, and the client holds out their arm for the nurse. Self‑confidence For an invasive procedure or surgery, the client is Articulate communication required to provide written consent. Assertiveness State laws regulate who is able to give informed consent. Laws vary regarding age limitations and emergencies. VALUES Nurses are responsible for knowing the laws in the state Caring of practice. Autonomy The nurse must verify that consent is informed and Respect witness the client sign the consent form. Empowerment Signing an informed consent form The form for informed consent must be signed by a competent adult. ◯ Emancipated minors (minors who are independent from their parents [a married minor]) can provide informed consent for themselves. The person who signs the form must be capable of understanding the information provided by the health care professional who will be providing the service. The person must be able to fully communicate in return with the health care professional. When the person giving the informed consent is unable to communicate due to a language barrier or hearing impairment, a trained medical interpreter must be provided. Many health care agencies contract with professional interpreters who have additional skills in medical terminology to assist with providing information. 36 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES  Individuals authorized to grant consent for another person Advance directives The purpose of advance directives is to communicate Parent of a minor a client’s wishes regarding end‑of‑life care should the Legal guardian client become unable to do so. Court‑specified representative The PSDA requires that all clients admitted to a health Client’s health care surrogate (individual who has the care facility be asked if they have advance directives. client’s durable power of attorney for health care/health ◯ A client who does not have advance directives must be care proxy) given written information that outlines their rights Spouse or closest available relative (state laws vary) related to health care decisions and how to formulate advance directives. INFORMED CONSENT RESPONSIBILITIES ◯ A health care representative should be available to help with this process. PROVIDER: Obtains informed consent. To do so, the provider must give the client the following. Complete description of the treatment/procedure COMPONENTS OF ADVANCE DIRECTIVES Description of the professionals who will be performing and participating in the treatment Two components of an advance directive are the living Description of the potential harm, pain, and/or will and the durable power of attorney for health care. discomfort that might occur Options for other treatments and the possible Living will consequences of taking other actions A living will is a legal document that expresses the The right to refuse treatment client’s wishes regarding medical treatment in the Risk involved if the client chooses no treatment event the client becomes incapacitated and is facing CLIENT: Gives informed consent. To give informed consent, end‑of‑life issues. Types of treatments that are the client must do the following. often addressed in a living will are those that have Give it voluntarily (no coercion involved). the capacity to prolong life. Examples of treatments Be competent and of legal age, or be an emancipated that are addressed are cardiopulmonary resuscitation, minor. (If the client is unable to provide consent, an mechanical ventilation, and feeding by artificial means. authorized person must give consent.) Living wills are legal in all states. However, state Receive sufficient information to make a decision based statutes and individual health care facility policies can on an informed understanding of what is expected. vary. Nurses need to be familiar with their state statute and facility policies. NURSE Most state laws include provisions that health care Witnesses informed consent. The nurse is responsible providers who follow the health care directive in a living for the following. will are protected from liability. ◯ Ensuring that the provider gave the client the necessary information ◯ Ensuring that the client understood the information Durable power of attorney for health care and is competent to give informed consent A durable power of attorney for health care/health care ◯ Having the client sign the informed proxy is a legal document that designates a health care consent document surrogate, who is an individual authorized to make health ◯ Notifying the provider if the client has more questions care decisions for a client who is unable. or does not understand any of the information The person who serves in the role of health care provided (The provider is then responsible for surrogate to make decisions for the client should be very giving clarification.) familiar with the client’s wishes. The nurse documents the following. Living wills can be difficult to interpret, especially in ◯ Reinforcement of information originally given by the face of unexpected circumstances. A durable power the provider of attorney for health care, as an adjunct to a living will, ◯ That questions the client had were forwarded to can be a more effective way of ensuring that the client’s the provider decisions about health care are honored. ◯ Use of an interpreter NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 37  Provider’s prescriptions NURSING ROLE IN CONFIDENTIALITY Unless a do not resuscitate (DNR) or allow natural death It is essential for nurses to be aware of the rights of (AND) prescription is written, the nurse should initiate clients in regard to privacy and confidentiality. Facility CPR when a client has no pulse or respirations. The policies and procedures are established in order to ensure written prescription for a DNR or AND must be placed compliance with HIPAA regulations. It is essential that in the client’s medical record. The provider consults nurses know and adhere to the policies and procedures. the client and the family prior to administering a HIPAA regulations also provide for penalties in the event DNR or AND. of noncompliance with the regulations. Additional prescriptions by the provider are based on the client’s individual needs and decisions and provide for comfort measures. The client’s decision is respected in PRIVACY RULE regard to the use of antibiotics, initiation of diagnostic The Privacy Rule of HIPAA requires that nurses protect all tests, and provision of nutrition by artificial means. written and verbal communication about clients. COMPONENTS OF THE PRIVACY RULE Only health care team members directly responsible NURSING ROLE IN ADVANCE DIRECTIVES for the client’s care are allowed access to the client’s Providing written information regarding advance records. Nurses cannot share information with other directives clients or staff not involved in the care of the client. Documenting the client’s advance directives status Clients have a right to read and obtain a copy of their Ensuring that advance directives are current and medical record, and agency policy should be followed reflective of the client’s current decisions when the client requests to read or have a copy of Recognizing that the client’s choice takes priority when the record. there is a conflict between the client and family, or No part of the client record can be copied except for between the client and the provider authorized exchange of documents between health care Informing all members of the health care team of the institutions. For example: client’s advance directives ◯ Transfer from a hospital to an extended care facility ◯ Exchange of documents between a general practitioner and a specialist during a consult Confidentiality and Client medical records must be kept in a secure area to information security prevent inappropriate access to the information. Using public display boards to list client names and diagnoses is restricted. Clients have the right to privacy and confidentiality in Electronic records should be password‑protected, and relation to their health care information and medical care must be taken to prevent public viewing of the recommendations. information. Health care workers should use only their Nurses who disclose client information to an own passwords to access information. unauthorized person can be liable for invasion of Client information cannot be disclosed to unauthorized privacy, defamation, or slander. individuals, including family members who request it The security and privacy rules of the Health Insurance and individuals who call on the phone. Portability and Accountability Act (HIPAA) were enacted ◯ Many hospitals use a code system in which to protect the confidentiality of health care information information is only disclosed to individuals who can and to give the client the right to control the release of provide the code. information. Specific rights provided by the legislation ◯ Nurses should ask any individual inquiring about a include the following: client’s status for the code and disclose information ◯ The rights of clients to obtain a copy of their medical only when an individual can give the code. record and to submit requests to amend erroneous or Communication about a client should only take place in incomplete information a private setting where it cannot be overheard by ◯ A requirement for health care and insurance providers unauthorized individuals. The practice of “walking to provide written information about how medical rounds,” where other clients and visitors can hear what information is used and how it is shared with is being said, is no longer sanctioned. Taped rounds also other entities (permission must be obtained before are discouraged because nurses should not receive information is shared) information about clients for whom they are not ◯ The rights of clients to privacy and confidentiality responsible. Change‑of‑shift reports can be done at the bedside as long as the client does not have a roommate and no unsolicited visitors are present. 38 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES  3.1 Advance directives NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 39  INFORMATION SECURITY Information technology Health information systems (HIS) are used to manage Informatics is the use of computers to systematically administrative functions and clinical functions. The resolve issues in nursing. The use of technology in clinical portion of the system is often referred to as the health care is increasing and most forms of clinical information systems (CIS). The CIS can be used communication are in electronic format. to coordinate essential aspects of client care. Examples of how a nurse can use the electronic In order to comply with HIPAA regulations, each format while providing client care include laptops for health care facility has specific policies and procedures documentation and the use of an automated medication designed to monitor staff adherence, technical protocols, dispensing system to dispense medications. computer privacy, and data safety. Databases on diseases and medications are available for INFORMATION SECURITY PROTOCOLS the nurse to review. These databases can also be used as Log off from the computer before leaving the a teaching tool when nurses are educating clients. workstation to ensure that others cannot view protected The nurse can review medications, diseases, procedures, health information (PHI) on the monitor. and treatments using an electronic format. Never share a user ID or password with anyone. Computers can be beneficial for use with clients who Never leave a client’s chart or other printed or written have visual impairments. PHI where others can access it. The Internet is a valuable tool for clients to review Shred any printed or written client information used for current medications and health questions. This is reporting or client care after it is no longer needed. especially true for clients who have chronic illnesses. Nurses should instruct clients to only review valid and credible websites by verifying the author, institution, USE OF SOCIAL MEDIA credentials, and how current the article is. A disclaimer The use of social media by members of the nursing will be presented if information is not medical advice. profession is common practice. The benefits to using Clients can access their electronic health record (EHR) social media are numerous. It provides a mechanism for which is part of e‑health. E‑health enables the client to nurses to access current information about health care make appointments online, review laboratory results, and enhances communication among nurses, colleagues, refill an electronic prescription, and review billing and clients and families. It also provides an opportunity information. The goal of e‑health is improved health for nurses to express concerns and seek support from care outcomes due to 24 hr access by the client and others. However, nurses must be cautious about the risk provider to the client’s health care information. of intentional or inadvertent breaches of confidentiality via social media. The right to privacy is a fundamental component of client care. Invasion of privacy as it relates to health Legal practice care is the release of client health information to others In order to be safe practitioners, nurses must understand without the client’s consent. Confidentiality is the duty the legal aspects of the nursing profession. of the nurse to protect a client’s private information. Understanding the laws governing nursing practice The inappropriate use of social media can result allows nurses to protect client rights and reduce the risk in a breach of client confidentiality. Depending on of nursing liability. the circumstances, the consequences can include Nurses are accountable for practicing nursing in termination of employment by the employer, discipline accordance with the various sources of law affecting by the board of nursing, charges of defamation nursing practice. It is important that nurses know or invasion of privacy, and in the most serious of and comply with these laws. By practicing nursing circumstances, federal charges for violation of HIPAA. within the confines of the law, nurses are able to do the following. Protecting yourself and others ◯ Provide safe, competent care Become familiar with facility policies about the use of ◯ Advocate for clients’ rights social media, and adhere to them. ◯ Provide care that is within the nurse’s scope Avoid disclosing any client health information online. of practice Be sure no one can overhear conversations about a client ◯ Discern the responsibilities of nursing in relation when speaking on the telephone. to the responsibilities of other members of the Do not take or share photos or videos of a client. health care team Remember to maintain professional boundaries when ◯ Provide care that is consistent with established interacting with clients online. standards of care Never post a belittling or offensive remark about a ◯ Shield oneself from liability client, employer, or coworker. Report any violations of facility social media policies to the nurse manager. 40 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES  SOURCES OF LAW State laws Federal regulations The core of nursing practice is regulated by state law. Each state has enacted statutes that define the Federal regulations have a great impact on nursing parameters of nursing practice and give the authority practice. Some of the federal laws affecting nursing to regulate the practice of nursing to its state board practice include the following. of nursing. HIPAA ◯ Boards of nursing have the authority to adopt Americans with Disabilities Act (ADA) rules and regulations that further regulate nursing Mental Health Parity Act (MHPA) practice. Although the practice of nursing is similar Patient Self‑Determination Act (PSDA) among states, it is critical that nurses know the laws Uniform Anatomical Gift Act (UAGA) and rules governing nursing in the state in which National Organ Transplant Act (NOTA) they practice. Emergency Medical Treatment and Active Labor ◯ The laws and rules governing nursing practice Act (EMTALA) in a specific state can be accessed at the state Criminal and civil laws board’s website. ◯ Boards of nursing have the authority to both issue Criminal law is a subsection of public law and relates to and revoke a nursing license. Boards can revoke or the relationship of an individual with the government. suspend a nurse’s license for a number of offenses, Violations of criminal law can be categorized as either a including practicing without a valid license, substance felony (a serious crime [homicide]) or misdemeanor (a use disorders, conviction of a felony, professional less serious crime [petty theft]). A nurse who falsifies a negligence, and providing care beyond the scope of record to cover up a serious mistake can be found guilty of practice. Nurses should review the practice act in breaking a criminal law. their states. Civil laws protect the individual rights of people. One ◯ Boards also set standards for nursing programs and type of civil law that relates to the provision of nursing further delineate the scope of practice for registered care is tort law. Torts can be classified as unintentional, nurses, licensed practical nurses, and advanced quasi‑intentional, or intentional. practice nurses. State laws vary as to when an individual can begin Unintentional torts practicing nursing. Some states allow graduates of Negligence: Practice or misconduct that does not meet nursing programs to practice under a limited license, expected standards of care and places the client at risk whereas some states require licensure by passing the for injury (a nurse fails to implement safety measures NCLEX® before working. for a client who has been identified as at risk for falls). Malpractice: Professional negligence (a nurse Good Samaritan laws administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies). Good Samaritan laws, which vary from state to state, protect nurses who provide emergency assistance outside Quasi‑intentional torts of the employment location. The nurse must provide a Invasion of privacy: Intrusion into a client’s private standard of care that is reasonable and prudent. affairs or a breach of confidentiality (a nurse releases the medical diagnosis of a client to a member of the press). Licensure Defamation: False communication or communication with careless disregard for the truth with the intent to Until the year 2000, nurses were required to hold a injure an individual’s reputation. current license in every state in which they practiced. ◯ Libel: Defamation with the written word or This became problematic with the increase in the photographs (a nurse documents in a client’s health electronic practice of nursing. For example, a nurse in record that a provider is incompetent). one state interprets the reading of a cardiac monitor ◯ Slander: Defamation with the spoken word (a nurse and provides intervention for a client who is physically tells a coworker that she believes a client has been located in another state. Additionally, many nurses cross unfaithful to the spouse). state lines to provide direct care. For example, a nurse who is located near a state border makes home visits on Intentional torts both sides of the state line. Assault: The conduct of one person makes another To address these issues, the mutual recognition model person fearful and apprehensive (threatening to place a of nurse licensure (the Nurse Licensure Compact [NLC]) nasogastric tube in a client who is refusing to eat). has been adopted by many states. This model allows Battery: Intentional and wrongful physical contact with nurses who reside in a NLC state to practice in another a person that involves an injury or offensive contact NLC state. Nurses must practice in accordance with (restraining a client and administering an injection the statues and rules of the state in which the care against their wishes). is provided. State boards can prohibit a nurse from False imprisonment: A competent person not at risk for practicing under the NLC if the license of the nurse has injury to self or others is confined or restrained against been restricted by a board of nursing. their will (using restraints on a competent client to prevent their leaving the health care facility). NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 41  Nurses who do not reside in a NLC state must practice STANDARDS OF CARE (PRACTICE) under the state‑based practice model. In other words, Nurses base practice on established standards of care or if a nurse resides in a non‑NLC state, the nurse must legal guidelines for care. These standards of care can be maintain a current license in every state in which they found in the following. practice. Some states now require background checks ◯ The nurse practice act of each state with licensure renewal. It is illegal to practice nursing These acts govern nursing practice, and legal with an expired license. guidelines for practice are established and The Enhanced Nurse Licensure Compact (eNLC) was enforced through a state board of nursing or other revised in 2017. It aligned licensing standards (criminal government agency. history background checks) in an effort to bring more Nurse practice acts vary from state to state, making states into the compact. Nurses in eNLC states have one it obligatory for the nurse to be informed about multistate license, with the ability to practice in-person their state’s nurse practice act as it defines the legal or via telehealth in both their home state and other parameters of practice. eNLC states. ◯ Published standards of nursing practice: These are developed by professional organizations (the American Nurses Association, National Association MALPRACTICE of Practical Nurse Education and Services, Inc.) and (PROFESSIONAL NEGLIGENCE) specialty organizations (the American Association of Malpractice is the failure of a person with professional Critical Care Nurses; Wound, Ostomy and Continence training to act in a reasonable and prudent manner. Nurses Society; and Oncology Nurses Society). The terms “reasonable and prudent” are generally used ◯ Accrediting bodies (The Joint Commission) to describe a person who has the average judgment, ◯ Originally mandated quality assurance programs, foresight, intelligence, and skill that would be expected which have evolved into quality improvement of a person with similar training and experience. (3.2) ◯ Sentinel event reporting: “An unexpected occurrence Professional negligence issues that prompt most involving death or serious or psychological injury, or malpractice suits include failure to do the following. the risk thereof” ◯ Follow either professional or facility established ◯ Failure Mode and Effects Analysis: Examines standards of care all potential failures in a design, including ◯ Use equipment in a responsible and event sequencing risks, vulnerabilities, and knowledgeable manner improvement areas ◯ Communicate effectively and thoroughly with ◯ National Patient Safety Goals: Augments core the client measures and promotes client safety through client ◯ Document care that was provided identification, effective staff communication, safe Nurses can avoid being liable for negligence by doing medication use, infection prevention, safety risk the following. identification, and preventing wrong‑site surgery ◯ Following standards of care ◯ Health care facility policies and procedures ◯ Giving competent care Policies and procedures, maintained in the ◯ Communicating with other health team members facility’s policy and procedure manual, establish ◯ Developing a caring rapport with clients the standard of practice for employees of ◯ Fully documenting assessments, interventions, that institution. and evaluations These manuals provide detailed information about how the nurse should respond to or provide care in specific situations and while performing client care procedures. Nurses who practice according to institutional policy are legally protected if that standard of care still results in an injury. For example, if a client files a complaint with the board of nursing or seeks legal counsel, the nurse who has followed the facility’s policies will not usually be charged with misconduct. It is very important that nurses are familiar with their institution’s policies and procedures and provide client care in accordance with these policies. For example: ☐ Assess and document findings postoperatively according to institutional policy. ☐ Change IV tubing and flush saline locks according to institutional policy. 42 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES  Standards of care guide, define, and direct the level of Health care providers who are found guilty of care that should be given by practicing nurses. They misappropriation of controlled substances also can also are used in malpractice lawsuits to determine if be charged with a criminal offense consistent with that level was maintained. the infraction. Nurses should refuse to practice beyond the legal scope Behaviors can be difficult to detect if the impaired nurse of practice and/or outside of their areas of competence is experienced at masking the substance use disorder. regardless of reason (staffing shortage, lack of appropriate personnel). Nurses should use the formal chain of command to BEHAVIORS CONSISTENT WITH A SUBSTANCE USE DISORDER verbalize concerns related to assignment in light of current legal scope of practice, job description, and area Smell of alcohol on breath or frequent use of strong of competence. mouthwash or mints Impaired coordination, sleepiness, shakiness, and/or slurred speech IMPAIRED COWORKERS Bloodshot eyes Mood swings and memory loss Impaired health care providers pose a significant risk to Neglect of personal appearance client safety. Excessive use of sick leave, tardiness, or absences after a A nurse who suspects a coworker of using alcohol or weekend off, holiday, or payday other substances while working has a duty to report Frequent requests to leave the unit for short periods of the coworker to appropriate management personnel time or to leave the shift early as specified by institutional policy. At the time of the Frequently “forgetting” to have another nurse witness infraction, the report should be made to the immediate wasting of a controlled substance supervisor (the charge nurse, to ensure client safety). Frequent involvement in incidences where a client Health care facility policies should provide guidelines assigned to the nurse reports not receiving pain for handling employees who have a substance use medication or adequate pain relief (impaired nurse disorder. Many facilities provide peer assistance provides questionable explanations) programs that facilitate entry into a treatment program. Documenting administration of pain medication to a Each state board of nursing has laws and regulations client who did not receive it or documenting a higher that govern the disposition of nurses who have been dosage than has been given by other nurses reported secondary to substance use. Depending on the Preferring to work the night shift where supervision is individual case, the boards have the option to require less or on units where controlled substances are more the nurse to enter a treatment program, during which frequently given time the nurse’s license can be retained, suspended, or revoked. If a nurse is allowed to maintain licensure, there usually are work restrictions put in place (working in noncritical care areas and being restricted from administering controlled medications). 3.2 Elements necessary to prove negligence EXAMPLE: CLIENT WHO IS A FALL RISK The nurse should complete a fall 1.  Duty to provide care as defined by a standard risk assessment for all clients upon Care that should be given or what a reasonably prudent nurse would do admission, per facility protocol. 2.  Breach of duty by failure to meet standard The nurse does not perform a fall Failure to give the standard of care that should have been given risk assessment during admission. 3.  Foreseeability of harm The nurse should know that failure Knowledge that failing to give the proper standard of care can to take fall‑risk precautions can cause harm to the client endanger a client at risk for falls. If a fall risk assessment is not 4.  Breach of duty has potential to cause harm (combines elements 2 and 3) performed, the client’s risk for falls Failure to meet the standard had potential to is not determined and the proper cause harm: relationship must be provable precautions are not put in place. 5.  Harm occurs The client falls out of bed Occurrence of actual harm to the client and breaks their hip. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 43  MANDATORY REPORTING ORGAN DONATION In certain situations, health care providers have a legal Organ and tissue donation is regulated by federal and obligation to report their findings in accordance with state laws. Health care facilities have policies and state law. procedures to guide health care workers involved with organ donation. Donations can be stipulated in a will or designated on ABUSE an official card. All 51 jurisdictions (50 states and the District of Federal law requires health care facilities to provide Colombia) have statutes requiring report of suspicion access to trained specialists who make the request to of child abuse. The statutes set out which occupations clients and/or family members and provide information are mandatory reporters. In many states, nurses are regarding consent, organ and tissues that can be mandatory reporters. donated, and how burial or cremation will be affected A number of states also mandate that health care by donation. providers, including nurses, report suspected violence Nurses are responsible for answering questions of neglect against vulnerable persons (older or regarding the donation process and for providing dependent adults). emotional support to family members. Nurses are mandated to report any suspicion of mistreatment following facility policy. TRANSCRIBING MEDICAL PRESCRIPTIONS COMMUNICABLE DISEASES Nurses might need to receive new prescriptions for client care or medications by verbal or telephone prescription. Nurses are also mandated to report to the proper agency When transcribing a prescription into a paper or (local health department, state health department) when electronic chart, nurses must do the following. a client is diagnosed with a communicable disease. ◯ Be sure to include all necessary elements of a A complete list of reportable diseases and a description prescription: date and time prescription was written; of the reporting system are available through the new client care prescription or medication including Centers for Disease Control and Prevention Web site. dosage, frequency, route of administration; and Each state mandates which diseases must be reported signature of nurse transcribing the prescription as in that state. There are more than 60 communicable well as the provider who verbally gave the prescription. diseases that must be reported to public health ◯ Follow institutional policy with regard to the time departments to allow officials to do the following. frame within which the provider must sign the ◯ Ensure appropriate medical treatment of diseases prescription (usually within 24 hr). (tuberculosis). ◯ Use strategies to prevent errors when taking a ◯ Monitor for common‑source outbreaks (foodborne: medical prescription that is given verbally or over the hepatitis A). phone by the provider. ◯ Plan and evaluate control and prevention plans Repeat back the prescription given, making sure to (immunizations for preventable diseases). include the medication name (spell if necessary), ◯ Identify outbreaks and epidemics. dosage, time, and route. ◯ Determine public health priorities based on trends. Question any prescription that seems ◯ Educate the community on prevention and treatment contraindicated due to a previous or concurrent of these diseases. prescription or client condition. 44 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES  Disruptive behavior Ethical practice Nurses experience incivility, lateral violence, and Ethics has several definitions, but the foundation of bullying at an alarming rate. The perpetrator can be ethics is based on an expected behavior of a certain a provider or a nursing colleague. Consequences of group in relation to what is considered right and wrong. disruptive behavior include poor communication, which Morals are the values and beliefs held by a person that can negatively affect client safety and productivity, guide behavior and decision‑making. resulting in absenteeism, decreased job satisfaction, Ethical theory analyzes varying philosophies, systems, and staff turnover. Some nurses can choose to leave the ideas, and principles used to make judgments profession due to these counterproductive behaviors. about what is right and wrong, good and bad. Two If disruptive behavior is allowed to continue, it is likely common types of ethical theory are utilitarianism to escalate. Over time, it can be viewed as acceptable in and deontology. that unit or department’s culture. ◯ Utilitarianism (teleological theory): Decision‑making based on what provides the greatest good for the greatest number of individuals TYPES OF DISRUPTIVE BEHAVIOR ◯ Deontological theory: Decision‑making based on Incivility is defined as an action that is rude, obligations, duty, and what one considers to be intimidating, and insulting. It includes teasing, joking, right or wrong dirty looks, and uninvited touching. Unusual or complex ethical issues might need to be Lateral violence is also known as horizontal abuse dealt with by a facility’s ethics committee. or horizontal hostility. It occurs between individuals ETHICAL PRINCIPLES are standards of what is right or who are at the same level within the organization. For wrong with regard to important social values and norms. example, a more experienced staff nurse can be abusive Ethical principles pertaining to the treatment of clients to a newly licensed nurse. Common behaviors include include the following. verbal abuse, undermining activities, sabotage, gossip, Autonomy: The ability of the client to make personal withholding information, and ostracism. decisions, even when those decisions might not be in Bullying behavior is persistent and relentless and is the client’s own best interest aimed at an individual who has limited ability to defend Beneficence: Care that is in the best interest of themselves. Bullying occurs when the perpetrator the client is at a higher level than the victim (for example, a Fidelity: Keeping one’s promise to the client about care nurse manager to a staff nurse). It is abuse of power that was offered that makes the recipient feel threatened, disgraced, Justice: Fair treatment in matters related to physical and vulnerable. For example, a nurse manager can and psychosocial care and use of resources demonstrate favoritism for another nurse by making Nonmaleficence: The nurse’s obligation to avoid causing unfair assignments or refusing a promotion. harm to the client Cyberbullying is a type of disruptive behavior using the Veracity: The nurse’s duty to tell the truth Internet or other electronic means. INTERVENTIONS TO DETER DISRUPTIVE BEHAVIORS Create an environment of mutual respect among staff. Model appropriate behavior. Increase staff awareness about disruptive behavior. Make staff aware that offensive online remarks about employers and coworkers are a form of bullying and are prohibited even if the nurse is off‑duty and it is posted off‑site from the facility. Avoid making excuses for disruptive behavior. Support zero tolerance for disruptive behavior. Establish mechanisms for open communication between staff nurses and nurse managers. Adopt policies that limit the risk of retaliation when disruptive behavior is reported. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 Professional Responsibilities 45  ETHICAL DECISION‑MAKING IN NURSING 3.3 The nurse’s role in Ethical dilemmas are problems for which more than one choice can be made, and the choice is influenced by the ethical decision‑making values and beliefs of the decision‑makers. These are EXAMPLES common in health care, and nurses must be prepared to apply ethical theory and decision-making. Caring for an adolescent client who is deciding whether to undergo A problem is an ethical dilemma if: an elective abortion even though ◯ It cannot be solved solely by a review of scientific data. their parents believe it is wrong ◯ It involves a conflict between two moral imperatives. Discussing options with parents who have to decide whether to ◯ The answer will have a profound effect on the An agent for the consent to a blood transfusion situation/client. client facing an for a child when their religion Nurses have a responsibility to be advocates, and to ethical decision prohibits such treatment identify and report ethical situations. Assigning staff nurses a higher ◯ Doing so through the chain of command offers some client load than recommended because administration has cut protection against retribution. the number of nurses per shift ◯ Some state nurse associations offer protection for Witnessing a surgeon discuss only nurses who report substandard or unethical practice. A decision‑maker surgical options with a client without Ethical decision‑making is the process by which a in regard to informing the client about more nursing practice conservative measures available decision is made about an ethical issue. Frequently, this requires a balance between science and morality. There are several steps in ethical decision‑making: ◯ Identify whether the issue is an ethical dilemma. ◯ State the ethical dilemma, including all surrounding issues and individuals involved. Active Learning Scenario ◯ List and analyze all possible options for resolving the dilemma, and review implications of each option. A nurse is preparing to serve on a committee that will ◯ Select the option that is in concert with the ethical review the policy on disruptive behavior. Use the ATI Active principle applicable to this situation, the decision Learning Template: Basic Concept to complete this item. maker’s values and beliefs, and the profession’s RELATED CONTENT: Describe another values set forth for client care. Justify why that one term used for lateral violence. option was selected. ◯ Apply this decision to the dilemma and evaluate NURSING INTERVENTIONS: Describe at least four the outcomes. interventions to deter disruptive behavior. The American Nurses Association Code of Ethics for Nurses and the International Council of Nurses’ Code of Ethics for Nurses are commonly used by professional nurses. The Code of Ethics for Licensed Practical/ Active Learning Scenario Key Vocational Nurses issued by the National Association for Practical Nurse Education and Services also serves as a Using the ATI Active Learning Template: Basic Concept set of standards for Nursing Practice. Codes of ethics are RELATED CONTENT: Lateral violence is also known available at the organizations’ websites. as horizontal abuse or horizontal hostility. The Uniform Determination of Death Act (UDDA) can be NURSING INTERVENTIONS Create an environment of mutual respect among staff. used to assist with end‑of‑life and organ donor issues. Model appropriate behavior. ◯ The UDDA provides two formal definitions of death Increase staff awareness about disruptive behavior. that were developed by the National Conference of Make staff aware that offensive online remarks about employers Commissioners on Uniform State Laws. Death is and coworkers are a form of bullying and is prohibited even if the nurse is off‑duty and it is posted off‑site of the facility. determined by one of two criteria. Avoid making excuses for disruptive behavior. Irreversible cessation of circulatory and Support zero tolerance for disruptive behavior. respiratory functions Establish mechanisms for open communication Irreversible cessation of all functions of the entire between staff nurses and nurse managers. Adopt policies that limit the risk of retaliation brain, including the brain stem when disruptive behavior is reported. ◯ A determination of death must be made in accordance NCLEX® Connection: Management of Care, Concepts of with accepted medical standards. Management 46 CHAPTER 3 Professional Responsibilities CONTENT MASTERY SERIES