Module 5 - Ethical and Legal Principles.docx

# Nurse Practitioner Core Competencies ## Module 5 - Ethical and Legal Principles - All NPs upon graduation are expected to meet the following competencies: scientific foundations, leadership, quality, practice inquiry, technology and information literacy, policy, health delivery systems, ethics,...

# Nurse Practitioner Core Competencies ## Module 5 - Ethical and Legal Principles - All NPs upon graduation are expected to meet the following competencies: scientific foundations, leadership, quality, practice inquiry, technology and information literacy, policy, health delivery systems, ethics, and independent practice. ## Scope of Practice - Determined by state legislative statues (State BON) – if BON is an answer option, it is usually correct - Defines NP roles and actions - Identifies competencies assumed to be held by all NPs who function in a particular role; varies broadly from state to state. ## Standard of Practice - Determined by ANA - Authoritative statements regarding the quality and type of practice that should be provided - Provide a way to judge nature of care provided - Can be used to legally describe standard of care that must be met by a provider; may be precise protocols or more general guidelines - The PMHNP is required by law to carry out care in accordance with what other reasonably prudent nurses would do in the same or similar circumstances. Thus, provision of high-quality care consistent with established standards is critical. ### Question: Any court of law that evaluates the standards of care provided by the PMHNP: a) compares the actions to the standard of care provided by a psychiatrist. b) considers what a reasonably prudent PMHNP would do in the same or similar circumstance. c) evaluates patient satisfaction data. d) reviews the NP's charts for similar patients. ### Question: The PHMNP is providing care to a patient with history of substance abuse, the patient is interested in receiving medication-assisted treatment (MAT) for their addition. What is the appropriate role of the PHMNP in this situation? A. Refer the patient to a substance abuse counselor for MAT. B. Inform the patient that as a PHMNP, they are not authorized to provide MAT. C. Assess the patient's suitability for MAT and is appropriate, initiate, and manage the treatment. D. Encourage the patient to seek MAT from a primary care physician. ## Confidentiality - Client's right to assume that info given to provider will not be disclosed .Protected under the Medical Record Confidentiality Act of 1995 (S. 1360). - Required provider to obtain signed medical authorization and consent forms to release medical records and info when requested by the family member or another healthcare provider - HIPAA does not allow the PMHNP to make most disclosures about psychotherapy notes for a patient's condition without their authorization - Two separate releases of information are required to release information on patient's chemical and psychiatric care to a third party ## Exceptions to Confidentiality - When appropriate persons or organizations determine that the need for information outweighs the principle of confidentiality - If a client reveals an intent to harm self or others - Information given to attorneys involved in litigation - Releasing records to insurance companies - Answering court orders, subpoenas, or summonses - Meeting state requirement for mandatory reporting of disease conditions (Medical conditions). - In cases of child or elder abuse ### Question: A 19-year-old college student comes to the PHMNP seeking treatment for depression. During the assessment, the patient reveals a history of substance use and experimentation with illicit drugs. The patient expresses concern about the confidentiality of this information. What is the appropriate response regarding confidentiality for the PHMNP? A. Reassure the patient that all information will remain confidential without exception. B. Inform the patient that confidentiality can be maintain unless there is risk of harm to self and others. C. Disclose D. ### Question: a 30-year-old patient with a history of bipolar disorder is involved in a child custody dispute following a divorce. One of the parents has requested access to the patients' medical records to support their case in court. The patient expresses concern about the confidentiality of the psychiatric information. What is the PHMNP most appropriate response? A. Assure ## Tarasoff Principle - Tarasoff v Regents at University of California, 1976 – Duty to warn potential victim of imminent danger of homicidal clients ### Question: During an outpatient psychiatric evaluation with a PHMNP, a depressed client refers persistent anger towards his former boss losing his job due to arguments and assaultive behaviors towards coworkers. The client has been waiting outside the plant in the afternoon, watching for the boss to leave to confront him regarding terminated employment. What is the responsibility does the PMHNP hold in this situation? A. Contact the client's boss to notify him of potential harm. B. Ask the patient to sign a "no harm to others" agreement and document in the chart. C. Advise the client to stop going to the plant and avoid any contact with the former boss. D. Consult state board of nursing regarding state laws requirement on reporting potential harm. ### Question: A 35-year-old patient, diagnosed with bipolar disorder, discloses to the PMHNP a history of violent outburst during manacic episodes. The patient expresses concern about potential harm to family members during the next manic episode. What is the PMHNP'S most appropriate action based on Tarasoff principle? A. Inform the family members about the patient's history and potential for harm. B. Document the patient's history but respect their confidentiality as there is no immediate plan for harm. C. Adjust the patient's medication to prevent future manic episodes and associated violence. D. Encourage the patient to attend anger management classes to address violent outburst. ### Question: During a regular follow-up appointment with a PMHNP, a patients reports to the PHMNP that her husband who is currently at work just told her that he wants to commit suicide. The PMHNP'S initial action answer D ## Informed Consent - Communication process between provider and client that results in client's acceptance or rejection of proposed treatment - An explanation of relevant information that enables the client to make an appropriate and informed decision - The right of all competent adults or emancipated minors - Emancipated minors: Persons younger than 18 years old who are married, parents, or self-sufficiently living away from the family domicile ## Elements of Informed Consent - Decisional Capacity (Competency) – patients should have the capacity (or ability) to make the decision - Competency - A legal, not medical concept; determination that a client can make reasonable judgments and decisions regarding treatment and other health concerns - Full Disclosure - The provider should disclose information on the treatment, test, or procedure in question, including the expected benefits and risks, and the likelihood (or probability) that the benefits and risks will occur - Comprehension - The patient should be able to comprehend the relevant information - Voluntariness: The patient should voluntarily grant consent, without coercion - Documentation: Provider must document in medical record that informed consent has been obtained from the client - If patients are not able to do all of the above components, family members, court-appointed guardians, or others (As determined by state law) may act as "surrogate decision-makers" and make decisions for them ### Question: The parent or legal guardian of a seven-year-old child must approve any medication orders, because a child of this age fails to meet which two of the five elements of informed consent? A. Autonomy and veracity B. Decision capacity (Competence) and comprehension C. Confidentiality and beneficence D. Disclosure of information and voluntariness ### Question: While providing a history, a patient request that a PMHNP disclose the information gathered with no one but the patients' spouse. answer C ## Ethical Principles - Justice – doing what is fair, fairness in all aspects of care - Justice leads us to ensure that care is provided on a fair and equal basis, regardless of patients' social or financial status, sexual orientation, or ethnicity. - Nonmaleficence – Doing no harm - Imminent danger - EXAMPLE: Stopping a medication that is causing harmful side effects or discontinuing a treatment strategy that is not effective and may be harmful - Beneficence - promoting well-being and doing good - Fidelity - being true and loyal - It also involves meeting - Veracity - Telling the truth - Patients need to know the truth about their medical conditions and treatment options - Autonomy – doing for self - Right to self-determinations - Allows healthcare teams to respect and support a patient's decision to accept or refuse life-sustaining treatments - Respect - treating everyone with equal respect ### Key differences between Veracity and Fidelity Focus: Veracity focuses on truthfulness and providing accurate information ### Question: A PMHNP is working in a community mental health center. A 45-year-old male with a history of schizophrenia presents for a routine follow up appointment. He has been stable on his current antipsychotic medication for the past six months and reports no significant side effects. During the appointment, he expresses his desire to discontinue his medication because he believes he no longer needs it, and the medication has harmful effects on his body. He states that he wants to try managing his symptoms without medication. What is the most appropriate action for the PMHNP. Answer B A. Respect the patient's autonomy and decision to discontinue medication and provide education on potential risks. B. Engage in a collaborative discussion with the patient about the risks and benefits of medication, explore his concerns, and consider adjusting the treatment plan if appropriate. C. Advise ### Question: A new male patient has a 10-year history of substance abuse, depression, and anxiety. He is requesting Xanax. Which principle should the PMHNP employ moving forward? A. Beneficence B. Fidelity C. Non-maleficence D. Veracity ### Question: A PMHNP prescribes Fluoxetine to a patient recently diagnosed with Major answer beneficence ### Question (12): A PMHNP decided to exclude a patient from a new answer: justice ### Question: Mr. Smithers, an involuntarily hospitalized patient experiencing psychotic symptoms, refuses to take any of his orderered medication because he believes "Jesus christ" Answer c psychiatric patient can refuse treatment ## Case Management - A system of controlled OVERSIGHT and authorization of SERVICES and benefits provided to clients consisting of coordinating care, ensuring quality outcomes, monitoring plan of care, and doing advocacy - Overall goal is to promote quality and cost-effective outcomes ### Question: A newly graduated PMHNP is working as a case manager for clients who have severe mental illness. As required, the PMHNP maintains in-depth and accurate client records of: A. appropriate history B. imaging results C. insurance coverage D. treatment plans ### According to the Stark Law You are not permitted to refer to family members for treatment of your patients as this could be seen as fraudulent by the Federal Gov't/Medicare ## Research ### PICOT Question - P - patient, population of patients, problem - I - intervention - C - comparison (another treatment or therapy, placebo) - O - outcome - T - time ### Question: A PMHNP is teaching hing a group of nursing students about the importance of formulation research questions in evidence- based practice. One student. Answer B ## Level of Evidence (LOE) ### Description: Level I - Evidence from a systematic review or meta-analysis of all relevant RCTs or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results. Level II - Evidence obtained from at least one well-designed RCT (e.g., large multi-site RCT) Level III - Cohort studies - PMHNP interventions follow evidence-based practice guidelines, are always client goal-directed and take into account the client's ethnicity and culture - A key part of the PMHNP work is to use empirical evidence in educating their clients, client's families, and the community about mental health, psychiatric illness, and effective management of illness - Cultural Syndrome = brief supportive therapy ### Question: A PMHNP notices that few substance abuse treatment programs apply evidence-based practice. The PMHNP wants to initiate such a treatment program to: A. implement the use of valid instruments. B. improve outcomes through analysis and synthesis of evidence. C. maximize interventions and increase skill utilization. D. optimize revenue-generating potential. ### Question: A PMHNP recognizes that a number of his or her colleagues are prescribing a certain medication for an off-label use. The PMHNP's initial action is to: A. conduct a literature search to determine whether data supports the off label use B. contact the pharmaceutical manufacturer to request related research findings. C. prescribe the medication for off-label use D. report the colleagues to the state BON ### Question: A PMHNP and a staff nurse are discussing the amount of time required to perform safety rounds on a psych unit. An initial evidence-based approach investigating this topic is to: A. conduct a time study. B. identify community standards. C. perform a literature search. D. survey the nursing staff ### Question: The evidence hierarchy ranks sources of knowledge according to the strength of information they provide. Which of the following would you find in Level 1 of an evidence hierarchy? A. Meta-analysis B. Cohort studies C. Opinions of expert committees D. Case control ### Question: While providing a history, a patient request that a PMHNP disclose the information gathered with no one but the patient's spouse. By respecting this request, the PMHNP demonstrates which component of therapeutic relationship? A. Informed consent B. Beneficence C. Confidentiality ## Rights of Patients - Confidentiality, least restrictive environment, give consent for treatment and withdraw consent at any time ### Question: Mr. Smithers, an involuntarily hospitalized patient experiencing psychotic symptoms, refuses to take any of his ordered medication because he believes "Jesus Christ told him I am the prophet and must fast for a year." Your actions should be based on your knowledge of which of the following? A. Psychiatric patients cannot refuse treatment. B. Psychiatric patients do not always know what is good for them. C. Psychiatric patients can refuse treatment. D. Psychiatric patients cannot be trusted to make good healthcare decisions and, therefore, the nurse's best clinical judgment should guide actions. ## Health Policy - Decisions, actions, and plans, by a group, community, or organization, to achieve specific healthcare goals; developed through laws and regulations. - An example is a Health and Human Services (HHS) policy that delineates what HHS is willing to expend to achieve the goal of one of its mandate projects - Four components of health policy - Process - formulation, implementation, and evaluation (FIE) - Policy Reform – changes in programs and practice - Policy Environment arena the process takes place in (government, media, public) - Policymakers – key players and stakeholders - Assess/address organizational barriers and facilitators - Meet with stakeholders ### Question: The PMHNP is asked to consult with a local inpatient psychiatric facility to provide nursing staff development. After meeting with the administrator to identify the nature of the problem requiring the consultation, the PMHNP's next step is to: A. create an interdisciplinary teaching team B. develop outcome measures C. market the educational plan D. utilize a survey to assess the educational needs of the staff ### Question: Before implementing evidence-based practice changes, an adult PMHNP's initial action is to: A. brainstorm with stakeholders and draft a detailed problem list B. compare data with internal and external benchmarks and coordinate ongoing education C. facilitate a collaborative multidisciplinary group to synthesize evidence and compare key themes D. identify potential barriers and facilitators that reflect patient's values and expectations ## Patient Advocacy - A nurse advocate ensures that patients' autonomy and self-determination is respected - Nurse advocates support the patient's best interests while respecting the family's important role - Nurses may sometimes need to advocate for patients against their families. With conflict, efforts should be made to find a common goal - Nurse advocates follow the patient's directives, not their own or the family's - Reduce the stigma of mental illness (Education) - Help clients receive available services - Advocating is getting up, showing, and telling people the value of what you do as a PMHNP - Promote mental health by participating in one or more of these professional organizations: - American Nurses Association (ANA) - American Psychiatric Nurses Association (APNA) - International Society of Psychiatric Nurses (ISPN) ### Question: The PMHNP has a law Bill in the senate legislature passed so that funds will be released to be used for housing the severe and persistently mentally ill. The PMHNP contacts eight persons and asks them to telephone the State Senate who heads the HHS committee, she asks them to tell the State Senator to vote to approve the bill. The NP is acting as an? A. Care provider B. Advocate C. Policymaker D. Stigma reduction agent ### Question: If a patient from a specific culture is refusing to accept any diagnosis of mental health disorder because of shame, what could be done to address this barrier? A. Educate the family. B. Political advocacy C. Public health concern D. Community education programs ## Just Culture of Safety - A just culture seeks to create an environment that encourages individuals to report mistakes so that the precursors to error can be better understood in order to fix system issues - In a just culture, individuals are continually learning, designing safe systems, and managing behavioral choices - Holds people accountable for their behaviors and investigates errors - Assess patient safety first ### Question: Mary is a PMHNP who is working in a Hospitalist role. Mary has encountered over five incidences in which attending psychiatrists and medical residents have been demeaning to nursing staff and not answering calls in the middle of the night or telling the nursing staff to write orders and the MD would sign off in the AM. Mary is concerned about errors and wants to improve quality, reduce errors to promote safety. What concept is Mary employing? A. Bullying B. Abuse C. Civil disobedience D. Just Culture ### Question: The PMHNP is concerned about access-to-care issues in the local community and wants to help develop health care policy to help patients access care more effectively. The NP knows one of the most effective avenues for developing and advocating for policy is: A. asking the clinic manager to explore options for access. B. organizing a political protest. C. working with the local chapter of the nurse's professional association. D. writing letters to the editor of the local newspaper ### Question: A hospital based adult PMHNP collaborates with a multidisciplinary team that is charged with establishing a psychiatric outpatient clinic. Advocating for the role of the ARPN, the NP initially educates the team that APRNS: A. are readily available to meet patient needs. B. can autonomously provide a full range of comprehensive services. C. can perform case management functions. D. provide a cost-effective care delivery. ### Question: A client with BPI d/o presents to your PMHNP office for a follow-up visit. During the visit, the client informs you that he no longer wants to be treated with medication, and he does not have bipolar disorder, that was a misdiagnosis. He further informs you he stopped all his medication 2 months ago and is here to thank you for your care and tell you that he no longer needs follow-up appointments. Understanding the ethical conflict, you use which of the following ethical principles in working with this client? A. Autonomy B. Nonmaleficence C. Justice D. Beneficence ### Question: The PMHNP is employed in a newly created attending role on a psychiatric inpatient unit. To promote an interprofessional environment, the NP: A. discussed the resistance directly with the physicians. B. assigns a role for all staff members in improving patient outcomes. C. educates staff members on the role of a PMHNP D. works with the nurse manager to organize all levels of nursing staff ### Question: A PMHNP is leading an interdisciplinary group that is developing treatment plans for patients with schizophrenia. During the second meeting, the nurse manager becomes resistant to the idea and negative about its implementation. This is an important project, and the support of the manager will be needed. The PMHNP's best response to the situation is to: A. meet individually with the nurse manager to discuss the perceived resistance B. report the situation to the nursing director and ask for administrative intervention C. revisit the initial goals of the group at the next meeting and ask for comments D. schedule another meeting of the group and move through the agenda since the majority of the group is very supportive - Habeas Corpus: A person can report an unlawful hospitalization to a court for the court to determine whether the hospitalization was required ## American Disabilities Act of 1990 - The ADA of 1990 prevents employers from discriminating against individuals with mental health disorders in employment decisions - The law mandates that reasonable accommodations need to be made for an individual ## Quality Improvement - Projects designed to improve systems, decrease cost, and improve productivity - Provides standardized methods to identify gaps in practice and systems to evaluate ways to improve structure, function, and resources in care delivery within complex health systems ## Process of quality improvement (PDSA) - Plan - plan the change - Do - carry out the plan - Study - examine the results - Act - decide what actions will improve the process ### Question: The chief nursing officer of a large behavioral health system approached the PMHNP to discuss the new Healthcare Effectiveness Data and Information Set (HEDIS) behavioral health measures and specifications. The PMPHNP is asked to do a retrospective chart review of all hospital discharge clients who received a follow-up visit within 7 days of discharge and within 30 days of discharge. The PMHNP has been asked to engage in which of the following? A. Needs assessment project B. Plan, do, study, act project C. A task that is outside of the PMHNP's scope of practice D. Quality improvement initiative ### Question:In a quality assurance program, a retrospective audit involves: A. examining the charts of discharged patients and using specific criteria to determine the quality of patient care B. inspecting the facility to monitor the therapeutic quality of environment and to suggest improvements C. reviewing patient charts to determine how appropriately hospital resources are being used D. using a case conference format for staff to discuss ways to improve a particular patient's care ### Question: The PMHNP is responsible for initiating quality improvement at a community mental health clinic. The effective strategy for evaluating the clinic's services is to: A. a chart review analysis B. a root cause analysis C. a plan-do-study-act process D. failure effect mode analysis #### Rationale - Root cause analysis (RCA) is defined as a collective term that describes a wide range of approaches, tools, and techniques used to uncover cause of problems - Failure modes and effects analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are in ### Question: The PMHNP in a hospital-based quality improvement project. The NP reviews four charts per month of a NP colleague to ensure diabetes protocols are met. This process is a: A. Core competency B. Force field analysis C. Peer review D. Risk analysis #### Rationale - Core Competency – the ability to practice nursing that meets the needs of clients care by using logical thinking and accurate nursing skills - Forced Field Analysis – looks at forces that are either driving movement toward a goal (helping forces) or blocking movement toward a goal (hindering forces) - Risk Analysis – It is an ongoing process that should provide an organization with a detailed understanding of its risks and information necessary to address those risks in a timely manner ## Reflective Practice - Linking theory to practice - Enhances critical thinking to problem-solve and enhance clinical reasoning and decision-making - Goal is to improve practice ## Patient-Centered Care Model - Sociocultural Competence - Understand and consider culture, economic and educational status, health literacy level, family patterns and situation, and traditions (including alternative and folk remedies); communicate in language and at a level that the client understands ### Question: The PMHNP evaluates a new adult patient via telemedicine. The patient has questions about a new medication that he or she recently started. The nurse practitioner decides to provide psychoeducation and to: A. E-mail drug information and resources B. Encourage the patient to seek information on the internet. C. Have a phone conference with a family member. D. Refer patient to a local primary care provider ### Question: A 69-year-old Cameroonian female, who recently moved to the US 4 weeks ago, comes to your clinic for an evaluation. Her first language is French, and she does not speak English. She did not finish high school and has problems with reading and writing. AS the PMHNP, what is your priority disparity to address with this patient? A. Race B. Age C. Reading Level D. Health Literacy ### Question: The members of a second-generation family of Mediterranean ancestry express concern about their immigrant grandmother's behavior. She persists in wearing heavy black clothing, secludes herself from the family, and prays throughout the day. Although she has no known health problems and appears to be healthy, she frequently discusses her impending death. The PMHNP assess the grandmother based on the knowledge that: A. cultural factors may negate the significance of seemingly obvious symptoms B. religious fixations are common in delusional systems C. she is exhibiting the classic signs of a major depressive disorder D. suicide is not uncommon among older adults ### Question:In counseling a 23-year-ol married, Hispanic mother who brought her 4-year-old son to clinic for "mal de ojo" with symptoms of fitful sleep, diarrhea, vomiting, and fever, the PMHNP: A. identifies what steps the mother has already tried in caring for the child's symptoms B. explains that the symptoms are most likely caused by viral infection C. educates about importance of maintaining fluid and electrolyte imbalance D. respects the mother's understanding of the child's illness ### Question:A PMHNP working in a child and adolescent psychiatric unit meets regularly with the staff nurses of an adolescent inpatient psychiatric unit to improve the nurses' therapeutic interactions with the patients. Each nurse keeps a journal describing clinical interaction with an adolescent and examines the factors that hinder the nurse's ability to interact therapeutically with the patient. The PMHNP reviews the entries and provides written feedback. This teaching strategy is known as: A. concept mapping B. discovery learning C. problem-based learning D. reflective practice #### Rationale - A concept map is a diagram that illustrates the relation between concepts - Discovery Learning – popular theory encourages learners to build on past experiences and knowledge, use their intuition, imagination and creativity, and search for new information to discover facts, correlations, and new truths - Problem-based learning (PBL) is a student-centered approach in which students learn about a subject by working in groups to solve an open-ended problem