MS CH 3 Issues in Nursing Practice.pdf

4068_Ch03_019-038 15/11/14 12:32 PM Page 19 3 Issues in Nursing Practice LINDA S.WILLIAMS, MICHELLE BLOCK, AND JAMES SHANNON LEARNING OUTCOMES 1. Identify factors influencing changes in the health care delivery system. 2. Describe safe health care practices. 3. Explain the significance of hospital-...

4068_Ch03_019-038 15/11/14 12:32 PM Page 19 3 Issues in Nursing Practice LINDA S.WILLIAMS, MICHELLE BLOCK, AND JAMES SHANNON LEARNING OUTCOMES 1. Identify factors influencing changes in the health care delivery system. 2. Describe safe health care practices. 3. Explain the significance of hospital-acquired conditions. 4. Describe four leadership styles. 5. Discuss the LPN/LVNs role in leadership and delegation. 6. Describe the importance of ethics in health care. 7. Explain the steps of the ethical decision-making model. 8. Discuss moral distress and its effect on nursing care. 9. Identify where the regulation of nursing practice is defined. 10. Define the Health Insurance Portability and Accountability Act (HIPAA) of 1996. 11. Describe guidelines for professional use of social media. 12. Discuss how to provide quality care and limit liability. KEY TERMS administrative laws (ad-MIN-i-STRAY-tive LAWZ) autocratic leadership (AW-tuh-KRAT-ik LEE-der-ship) autonomy (aw-TAWN-uh-MEE) beneficence (buh-NEF-i-sens) civil law (SIH-vil LAW) code of ethics (KOHD OF ETH-icks) confidentiality (KON-fi-den-she-AL-i-tee) criminal law (KRIM-i-nuhl LAW) delegation (DELL-a-GAY-shun) democratic leadership (DEM-ah-KRAT-ik LEE-der-ship) deontology (DEE-on-TOL-o-gee) diagnosis-related groups (DYE-ag-NOH-sis ree-LAY-ted GROOPS) electronic medical record (e-LECK-tron-ick MED-ick-uhl WRECK-ord) ethics (ETH-icks) fidelity (FAH-dell-eh-tee) informatics (IN-for-mat-icks) justice (JUSS-tiss) laissez-faire leadership (LAYS-ay-FAIR LEE-der-ship) leadership (LEE-der-ship) liability (LYE-uh-BIL-i-tee) limitation of liability (LIM-i-TAY-shun OF LYE-uh-BILi-tee) maleficence (ma-LEF-i-cence) malpractice (mal-PRAK-tiss) morality (moh-RAL-i-tee) moral distress (moh-Ral DIS-tress) negligence (NEG-la-ghunt) nonmaleficence (NON-muh-LEF-i-sens) paternalism (puh-TER-nuhl-izm) principles (PRIN-sih-pulz) respondeat superior (res-POND-ee-et sue-PEER-ee-or) standard of best interest (STAN-derd OF BEST IN-ter-est) summons (SUH-muns) therapeutic privilege (Ther-uh-PU-tik PRIV-uh-lej) torts (TORTS) utilitarian (yoo-TILL-ih-TAR-ee-en) values (VAL-yooz) veracity (VER-ah-sit-tee) The author acknowledges the contributions to this chapter by Maryanne PietraniecShannon RN, PhD for the “Correctional Nursing” section. 19 4068_Ch03_019-038 15/11/14 12:32 PM Page 20 20 UNIT ONE Understanding Health Care Issues HEALTH CARE DELIVERY Health–Illness Continuum The term health–illness continuum describes the continually shifting levels of health experienced by each person. One end of the continuum represents high-level health. The other end represents poor health and impending death. We all move about the continuum throughout our lives. Health Care Delivery Systems A focus on pre vention and providing services from birth to death under one integrated system is being used by many health care systems. Hospital consolidations led to health care systems that can cover large geographic areas. Hospitals pro vide the integrated care delivery network for the system (Fig. 3.1). Factors Influencing Health Care Change Do you like change? Well, today’s health care deli very is being influenced by many evolving changes, which will have an impact on your career . Some examples of these changes include the 2010 Patient Protection and Affordable Care Act (discussed later); the expanding role of technology in health care including electronic medical records; mobile health with tablets, smartphones, and digital apps; telehealth with telephones and online video; remote patient monitoring; robotics; the use of evidence to guide practice (see Chapter 2); and antibiotic-resistant infectious organisms that continue to emerge. Nursing informatics is a specialty area that deals with the study and use of information technology within nursing practice. There are educational programs with majors in informatics to consider as you continue your education. The changing characteristics of the American population are also influencing health care deli very with increases in the size of the population, number of older adults, and population’ s Home Health Services Ambulance Service Subacute Care Extended Care Facility Consumer Education Center Rehabilitation Services Acute Care Hospital Ambulatory Surgery Primary Care Clinics, Offices Hospice FIGURE 3.1 An integrated health care system. Diagnostic Centers cultural diversity (U.S. Census Bureau, 2010). These and other changes make learning a constant need in today’s health care environment. We hope that you will be fle xible and embrace change throughout your career! EVIDENCE-BASED PRACTICE Clinical Question Does use of information technology in the form of an Interactive Preventive Health Record (IPHR) increase the use of preventative health services? Evidence 4500 patients were randomly invited to use an IPHR that provided personal health records, education, and reminders. Use of preventative services significantly increased by 2.3% in those using the IPHR over those who were not. Furthermore, the number of patients who were up to date on all recommended preventative services was double in the IPHR group. Implications for Nursing Practice Encouraging the use of patient-centered interactive technology might help improve patient health. REFERENCES Krist, A. H., Woolf, S. H., Rothemich, S. F, Johnson, R. E., Peele, J. E., Cunningham, T. D., Longo, D. R., Bello, G. A., Matzke, G. R. (2012). Interactive preventive health record to enhance delivery of recommended care: A randomized trial. Annals of Family Medicine, 10, 312–319. Safe Practice Preventing harmful adverse events is a concern of several organizations that promote safe health care practices. A culture of safety should exist within the health care system and nursing. The Joint Commission’s National Patient Safety Goals are updated annually, and sentinel events identify safety concerns and the interventions for them ( www.jointcommission.org). Examples of sentinel events are surgery on the wrong body part or death/loss of function associated with a f all within a facility. The National Quality Forum (NQF) (2011) has identified “serious reportable e vents” (SRE). These 29 e vents that should not occur in various health care settings are found at www.qualityforum.org/Topics/SREs/List_of_SREs.aspx. Medication errors are of primary concern, and interv entions to prevent them are being researched and implemented. The Institute for Safe Medication Practices has interventions to reduce medication errors such as the Error -Prone Abbreviations List, Do Not Crush List, Drug Names Written With Tallman Letters, Letters to Distinguish between Similar Looking Drug Names to Prevent Giving the Wrong Drug, and High Alert Medications ( http://ismp.org/default.asp). No 4068_Ch03_019-038 15/11/14 12:32 PM Page 21 Chapter 3 interruption zones with brightly color tape or wearing bright color vests/sashes as an alert to a void distractions are used at some agencies with great results. Distractions during medication administration can increase errors, so you should always stay focused and avoid interruptions during this time. Promote a culture of safety and ask your coworkers to avoid interrupting others during medication administration. Reducing errors requires everyone to be engaged and vigilant at all times during patient care. Patient Protection and Affordable Care Act Known in brief as the Affordable Care Act, the 2010 Patient Protection and Affordable Care Act’s phase-in continues through 2020 (Fig. 3.2). Its purpose is to pro vide insurance reforms that protect consumers from insurance industry abuses, reduce the cost of health care, increase the quality of health care, and increase health insurance availability for more Americans. Key changes of the act are listed in Table 3.1. For more information, visit www.hhs.gov/healthcare. Medicare and Diagnosis-Related Groups To learn more about safe health care practices, visit the Institute for Healthcare Improvement website at www.ihi.org/IHI/Programs/IHIOpenSchool. Did you know that a drug made for one type of administration route, such as intravenous (IV), cannot be safely given by another route such as by NG or PEG tube? Serious effects, including death, can occur because the drug dosages or drug makeup is specific to the route. Get a new order for an alternate route if needed to obtain the proper drug form. This website shows examples of adverse effects when drugs were given incorrectly. Keep your patients safe! Medicare was created in 1965 to pro vide health insurance as part of the Social SecurityAct. It is run by the U.S. government and covers all people aged 65 and older and people younger than age 65 who ha ve disabilities and are eligible for Social Security. It is funded by a deduction from e very person’s paycheck that is matched by the go vernment. Several Medicare plan options are offered, including Original Medicare, Medicare Health Plans, and prescription drug co verage for everyone with Medicare. There are two parts of coverage in the Original Medicare plan. Part A covers inpatient hospital care, skilled nursing facilities, hospice services, and some home care.There is no premium or deductible for P art A. Part B is medical insurance that covers physician costs, outpatient services, some LOWERING HE ITY & ALT L A HC U Q AR G N E VI Protect Against Health Care Fraud Benefits of the AFFORDABLE CARE ACT Beneϐits for Women Providing insurance options, covering preventive services, and lowering costs. S ST CO Rx Discounts For Seniors Free Preventive Care Young Adult Coverage Coverage available to children up to age 26. Small Business Tax Credits CO U TO NS ER ALT Health Insurance Marketplace Pre-existing Conditions PR OTE Consumer Assistance C TIO A E CC SS NS Yearly wellness visit and many free preventive services for some seniors with Medicare. Holding Insurance Companies Accountable Insurers must justify any premium increase of 10% or more before the rate takes effect. TIMELINE FIGURE 3.2 Key features of the Affordable Care Act. (From the U. S. Department of Health and Human Services, 2013.) Strengthening Medicare HE NEW HCA RE for Americans M 21 ECONOMIC ISSUES LEARNING TIP IM PR O Issues in Nursing Practice October January March Future Open enrollment begins Coverage begins Open enrollment closes All Americans have access to affordable health care 4068_Ch03_019-038 15/11/14 12:32 PM Page 22 TABLE 3.1 AFFORDABLE CARE ACT OVERVIEW Year 2010 Consumer Protection Key Changes Patient Bill of Rights for protection from insurance abuses Prevention of child preexisting condition denial Prevention of coverage rescinding No lifetime benefit dollar limits Quality and Cost Lowering Small business tax credits for insurance premiums Medicare prescription drug relief Free preventive services Disease prevention funding programs Fraud reduction Increased Access to Affordable Care Coverage for preexisting conditions Young adult coverage until age 26 under parents’ plan Early retiree coverage Education funding to increase number of health care providers Insurance premium hike justification Medicaid funding increase Rural care payment increases Community health center expansion 2011 Quality and Cost Lowering Increased Access to Affordable Care Insurance Company Accountability 2012 Quality and Cost Lowering 2013 Quality and Cost Lowering Increased Access to Affordable Care 2014 Consumer Protection Medicare free preventive services Innovation center for quality and efficiency Community Care Transitions Program for hospital-discharged seniors Innovations to reduce Medicare costs Community First Choice Option to serve the disabled with home and community services via Medicaid Health care premium guidelines and containment Payment linked to quality outcomes for hospitals Accountable Care Programs provide incentives for physicians to provide quality care and reduce costs Electronic health record implementation to reduce paperwork Health disparities data collection: racial, ethnic, and language Expanded Medicaid preventive care Bundling flat rate payments for care episode to incent efficiency and quality Open enrollment for health insurance marketplace starts Medicaid payment increase to primary care doctors Preexisting condition or gender denial prevented Annual dollar limits prohibited Coverage for clinical trial participants protected Quality and Cost Lowering Health insurance marketplace begins Tax credits for middle class to make insurance affordable Small business tax credits for insurance premiums increases Increased Access to Affordable Care Medicaid eligibility (earn less than 133% of poverty level) increases Individuals required to obtain insurance or pay a fee unless exempt 2015 Quality and Cost Lowering Physician payment based on quality of care provided Adapted from U.S. Department of Health & Human Services key features of the Affordable Care Act by year. Retrieved September 3, 2013, from www.hhs.gov/healthcare/facts/timeline/timeline-text.html#2010 4068_Ch03_019-038 15/11/14 12:32 PM Page 23 Chapter 3 home care, supplies, and other things not co vered by Part A. Some preventive services might also be co vered. A monthly premium and yearly deductible are paid for P art B coverage. For more information, visit www.medicare.gov. Congress created the diagnosis-related group (DRG) payment system in 1983 for 470 diagnostic cate gories to help control costs in the Medicare program, which pre viously had no reimbursement limits. All hospitals were paid the same fee for patients in the same diagnostic cate gory regardless of length of stay and supply costs. The original DRG system has under gone modifications through the years, and today several DRG systems are in use that take into consideration all populations, complications, and comorbidities. Hospitals lose money if the patient’s costs exceed the DRG payment and make money if the costs are less than the payment. Hospital-Acquired Conditions and Present-on-Admission Reporting In 2008, the Centers for Medicare and Medicaid Services implemented a change for Medicare Severity DRG payments to acute inpatient prospecti ve payment system hospitals. This policy is called the Hospital-Acquired Conditions (HAC) and Present on Admission (POA) Indicator Reporting. Box 3-1 shows the 11 cate gories of HACs (for updates, see www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment /HospitalAcqCond/Hospital-Acquired_Conditions.html). At discharge, if certain conditions are not POA, hospitals do not receive additional reimbursement for those conditions. F or example, if a patient w as admitted with a strok e (primary diagnosis) and then developed a pressure ulcer that w as not present on admission (secondary diagnosis) that could ha ve been prevented, the hospital w ould receive reimbursement only for the primary diagnosis of strok e. The hospital would have to absorb the cost of care for the pressure ulcer. With this requirement, nurses must carefully assess and document patient conditions that are POA to show that they did not occur during the hospitalization. Providing safe, quality care and educating patients to prevent complications, such as the need to do leg exercises, turn every 2 hours, or ambulate, are essential to prevent these conditions. Documenting interventions, education provided, and the patient’s refusal to participate (if applicable) are essential to help ensure reimbursement for secondary diagnoses. Medicaid The Medicaid payment system w as also created in 1965 to provide health insurance as part of the Social Security Act for low-income or disabled persons younger than age 65 and their dependent children. Some low-income people older than age 65 can also qualify. Medicaid funding comes from federal, state, and local taxes. Benefits for Medicaid vary from state to state. Managed Health Care Health maintenance or ganizations (HMOs) deli ver health care services to individuals who enroll in this type of prepaid Box 3-1 Issues in Nursing Practice 23 Categories of HospitalAcquired Conditions The Centers for Medicare and Medicaid Services identified the following 11 categories of hospital-acquired conditions as those that increase health care costs or that could have been pre vented by using e vidence-based guidelines: Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma • Fractures • Dislocations • Intracranial Injuries • Crushing Injuries • Burns • Other Injuries Manifestations of Poor Glycemic Control • Diabetic Ketoacidosis • Nonketotic Hyperosmolar Coma • Hypoglycemic Coma • Secondary Diabetes With Ketoacidosis • Secondary Diabetes With Hyperosmolarity Catheter-Associated Urinary Tract Infection Vascular Catheter-Associated Infection Surgical Site Infection After: • Coronary Artery Bypass Graft—Mediastinitis • Bariatric Surgery for Obesity • Laparoscopic Gastric Bypass • Gastroenterostomy • Laparoscopic Gastric Restrictive Surgery • Certain Orthopedic Procedures • Spine • Neck • Shoulder • Elbow • Cardiac Implantable Electronic Device Deep Vein Thrombosis/Pulmonary Embolism • Total Knee Replacement • Hip Replacement Iatrogenic Pneumothorax With Venous Catheterization Source: Centers for Medicare & Medicaid Services. (2013). Hospital-acquired conditions. Retrieved July 12, 2013, from www.cms.gov/Medicare /Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital -Acquired_Conditions.html group practice health program. The purpose of an HMO is to reduce overlapping services and pro vide quality and costeffective care. Healthy patients require fewer services, so preventive care is promoted. Preferred pro vider organizations (PPOs) are netw orks of pro viders who of fer care to plan members at set discounted rates. PPOs are designed to reduce 4068_Ch03_019-038 15/11/14 12:32 PM Page 24 24 UNIT ONE Understanding Health Care Issues costs to b usinesses that insure emplo yees. Hospitals and physicians develop a contract with employers to provide services at a negotiated fee. LEARNING TIP To understand what the term managed care means, reverse the words: care management. Managed care has led to fewer hospitalizations and shorter lengths of stay. Patients are using home health care for more complex needs. Case management is helping to ensure that the best patient outcome is achieved while controlling costs. NURSING AND THE HEALTH CARE TEAM Nursing is an integral part of the health care network. Nurses work as licensed practical nurses (LPNs) or licensed vocational nurses (LVNs), registered nurses (RNs), or registered nurses with advanced education and practice skills, which includes certified registered nurse practitioners (CRNPs), clinical nurse specialists (CNSs), certified nurse midwives (CNMs), certified registered nurse anesthetists (CRNAs), and doctors of nursing practice (DNP). Certified nursing assistants (CNAs) are trained to assist nurses in providing health care. Collaborative Care Nurses work in collaboration with other members of the health care team: • Licensed physicians provide medical care to patients after graduating from a college of medicine (MD) or osteopathic medicine (DO). • Physician assistants (PA-C [certified]), after graduating from a physician’s assistant program, work under the supervision of a physician and perform certain physician duties, such as history taking, physical examinations, and suturing of wounds. • Licensed pharmacists complete 5 or 6 years of college and dispense medications from prescriptions, consult with physicians, and provide medication information to patients. • Social workers usually have a master’s degree in social work (MSW), can be licensed clinical social workers (LCSW), and treat patients and their families with psychosocial issues. • Dietitians provide nutrition information, analyze nutritional needs, and calculate special dietary needs. • Licensed physical therapists complete a college physical therapy program and assist patients in reducing physical disability, bodily malfunction, movement dysfunction, and pain through evaluation, education, and treatment. • Physical therapy assistants, whose educational requirements vary, might complete 2 years of education and be licensed and then work under the supervision of a physical therapist. • Occupational therapists complete a bachelor’s or master’s program, can be registered (OTR), and assist patients in restoring self-care, work, and leisure skills that have been diminished as a result of developmental deficits or injury. • Speech and language pathologists typically complete a master’s program. They provide direct clinical services to those with communication or swallowing problems. • Respiratory therapists have a 2-year college degree, can be registered (RRT), and work with patients who have respiratory problems. • Respiratory therapy technicians have 1 year of education, can be certified (CRTT), and work under the supervision of a respiratory therapist to provide respiratory care. • Health unit secretaries manage clerical work. • Student nurses are enrolled in a nursing program and work under the supervision of nursing faculty in the clinical setting. LEADERSHIP IN NURSING PRACTICE A leader seeks to influence, moti vate, and enable others to achieve goals. Leadership skills are necessary for the LPN/LVN to effectively guide patient care and achieve patient care goals. Effective leaders in a health care setting must be kno wledgeable about management and supervisory processes. They must use critical thinking and be able to make decisions. They should be role models and an inspiration to others.A positive attitude and the use of humor are v aluable assets of good leaders. Ultimately, leaders must earn the respect of their coworkers to be successful. To prepare for a leadership role, learning and applying the following principles of leadership, supervision, and management is helpful. Leadership Styles There are three traditional leadership styles: (1) autocratic, (2) democratic, and (3) laissez-f aire. A fourth style called coaching is also used in health care settings. Autocratic (Authoritarian) Leadership An autocratic leader has a high degree of control. Almost no control is gi ven to others. In autocratic leadership, the leader determines the goals and plans for achieving the goals. Others are instructed on what to do and are not asked to provide input. The group usually achieves high-quality outcomes under this style of leadership. This is an efficient leadership style for emergency situations when decisions must be made quickly, such as when evacuating a building or responding to a cardiac arrest. Democratic (Participative) Leadership A democratic leader has a moderate de gree of control. Others are given some control and freedom. In democratic leadership, participation is encouraged in determining goals and plans for achieving the goals (Fig. 3.3). Decisions are made within the group. The leader assists the group by steering and teaching rather than dominating. The leader shares responsibility with 4068_Ch03_019-038 15/11/14 12:32 PM Page 25 Chapter 3 Issues in Nursing Practice 25 Organizing The purpose of or ganizing, the second step in the management process, is to pro vide an orderly en vironment that promotes cooperation and goal achie vement. Providing a framework for goals and the activities that accomplish them is the initial step in organization. Policies and procedures provide this framework as well as guidance for those carrying out tasks designed to accomplish the organization’s goals. Directing FIGURE 3.3 Group participation in decision making. the group. The group usually achieves high-quality outcomes and is more creative under this style of leadership. This is an efficient leadership style for most situations. With this type of leadership, group members have greater satisfaction and are motivated to achieve goals because they are active participants. Laissez-Faire (Delegative) Leadership A laissez-faire leader exerts no control over the group, which is given complete freedom for decision making. With laissezfaire leadership, no one is responsible for determining goals and plans for achieving the goals. This can produce a feeling of chaos. Little is accomplished under this leadership style, and the quality of outcomes is often poor. Coaching Leadership By emphasizing active listening, clear communication, support, and accountability, coaching leaders work with others to develop problem-solving skills that facilitate critical thinking, prioritization, and effective communication. This leadership style helps direct-care emplo yees feel more empo wered, valued, and respected. Management Functions The five major components in the management process are (1) planning, (2) organizing, (3) directing, (4) coordinating, and (5) controlling. Planning In the first step of the management process, a plan must be developed to ensure that desired patient care outcomes are achieved. To formulate the plan, desired outcomes or problems are identified and data about them are collected. Alternatives or solutions are considered using the collected data and input from others. A decision is then made about the best option or course of action. The leader should ensure that the choice is realistic and can be implemented. Involving others in the planning and decision-making process from beginning to end can increase acceptance at the time of implementation. Making assignments is the primary function of directing. One person, usually the nurse in charge or the team leader, makes the assignments for patient care. The nurse practice act in each state defines who can mak e assignments and dele gate care. Communication is important in directing. Assignments must be clearly and specifically stated. The person making assignments must be sure that each assignment is correctly under stood and should seek out the receiving person for clarification. Effective directing can be accomplished by pro viding verbal and written assignment information, making requests rather than giving orders, and giving instructions as needed. Coordinating Coordination is the process of looking at a situation to ensure that it is being handled in the most effective way for the organization or coordinating services for a patient.The nurse might assess a particular activity or issues related to patient care assignments. In a long-term care facility, for example, the nurse might want to review skin assessment and care throughout the facility to see if it is being done consistently and uniformly. If a concern is found, problem-solving techniques are used. Controlling The final phase of the management process is controlling to evaluate the accomplishment of the or ganization’s goals. Continuous quality improvement is linked with controlling. If the organization’s efficiency or ability to reach its goals is impaired, the use of the continuous quality impro vement model can facilitate correction of the concern (Fig. 3.4). Leadership and Delegation for the LPN/LVN LPN/LVNs are leaders and managers of care for the patients to whom they are assigned, under the supervision of an RN, health care provider (HCP), or a dentist as specified by each state nursing practice act. Beyond this application of a leader and manager role for the LPN/LVN, state nurse practice acts specify if the LPN/LVN can assume other leader or manager roles. Within this dependent role, some aspect of dele gation may be allowed. LEARNING TIP Review your state’s nurse practice act. Does your state allow LPN/LVNs to delegate? If so, to whom and what can be delegated? 4068_Ch03_019-038 15/11/14 12:32 PM Page 26 26 UNIT ONE Understanding Health Care Issues Assign responsibility for CQI Communicate results Describe scope of care Reevaluate action Identify important aspects of care Develop and implement action plan if needed Evaluate data and the set threshold Determine measures of quality Collect data Set threshold for acceptable evaluation FIGURE 3.4 A continuous quality improvement (CQI) model. Delegation is the act of empowering another person to act. Delegation occurs in a do wnward manner. RNs delegate to LPN/LVNs and unlicensed assisti ve personnel (U AP). LPN/LVNs, in certain circumstances, dele gate to LPN/LVNs and UAPs (as discussed later). When delegation occurs, responsibility for care is transferred to the delegatee, but accountability for the care remains with the dele gator. Guidelines for delegating can be found at www.ncsbn.org/1625.htm. The LPN/LVN might function as a team leader or charge nurse mainly in the long-term care setting, requiring some use of delegation to UAPs. When the LPN/LVN acts as a team leader or charge nurse, an RN delegates the authority to provide supervision and delegation of tasks. Team leaders are responsible for the coordination and delivery of care to each of the patients assigned to the team. They assess the patients assigned to the team to plan appropriate care and contrib ute to the nursing care plan. Team leaders receive information from team members and communicate patients’ needs to appropriate individuals. Because team leaders guide patient care provided by the team, the y must be kno wledgeable about safety policies, patients’ rights, and the accountability of being a team leader. All patients are entitled to quality care and treatment with dignity and respect. The team leader is accountable for all care provided by the team. Supervision involves initial direction for the task and then monitoring of the task and outcome at intervals. At the end of the team’s work shift, team leaders are responsible for transferring patient care to the oncoming team in a way that prevents communication breakdowns that result in patient harm. This hand-off communication is accomplished by reporting the patient’ s condition, status, and needs to the oncoming team leader (Fig. 3.5). Institutional policy specifies whether the RN or LPN/LVN communicates the report. Within the leadership role, the LPN/L VN must decide when delegation would most benefit the situation and the FIGURE 3.5 Communication of the patient’s status by a team leader when transferring the patient’s care to another team leader. patient. All nurses must follow the state practice act and the scope of practice when making any decisions regarding delegation. Consult the char ge nurse, team leader , and nurse practice act for your state when deciding if dele gation is appropriate. Ultimately, you must ask se veral important questions to determine when dele gation would best benefit the situation. These questions include the following: • Does the state practice act allow for delegation in this situation? • Does the person to whom I am delegating have the knowledge and education to perform this skill, and is it documented for me to make the decisions regarding delegation? • Would it benefit the patient if I delegated this skill to the support person? Delegation Process Delegation is a complex process. In each case, tak e the following steps, which encompass the decision to delegate, what to delegate, and to whom delegation can be made: 1. Know your state practice act rules for delegation. The LPN/LVN scope of practice usually does not provide legal authority for an LPN/LVN to delegate. However, some state board rules allow LPN/LVNs to delegate tasks that are within the LPN/LVNs scope of practice as long as the RN has given the LPN/LVN authority to delegate the tasks. 2. Identify the skills of the person to whom you might delegate to determine if he or she has the knowledge and ability to carry out the task. When selecting a team member to delegate tasks to, consider if there is potential for harm to the patient during the task, whether it is a complex task that will require problem solving, how predictable the outcome is, and how much interaction with the patient is needed. 4068_Ch03_019-038 15/11/14 12:32 PM Page 27 Chapter 3 Match the skills and talents of the team member to the task being delegated. Remember, nursing judgment can never be delegated. 3. Use the National Council of State Boards of Nursing’s (1995) five rights of delegation. Following these guidelines provides a framework for your decision-making process and comfort in knowing you used them to make good choices: • Right task—is it appropriate to delegate? • Right circumstances—is this situation safe and appropriate for delegating? • Right person—is this delegatee the appropriate person for the task and this patient’s needs? • Right communication—is there clear understanding between you and the delegatee for terms used, communication, and reporting needs? • Right supervision—is it defined how and when direct supervision will occur? Delegation requires trust. You should be comfortable with which tasks can be delegated and the team member to whom you are delegating the tasks. Also, it is important to know and understand each other’s methods of communicating so that miscommunications do not occur. When you first begin your career, the process of delegating can seem difficult. As with any skill, it takes practice to feel confident in carrying out the process. EDUCATIONAL AND CAREER OPPORTUNITIES FOR LPN/LVNS LPN/LVNs might seek additional education. Man y schools provide for an accelerated educational tract for LPN/L VNs seeking to become RNs. Advanced educational opportunities include a master’s degree or a doctoral de gree. Check with colleges/universities to see which program w ould best meet your needs for continuing your education. Post licensure certification for the LPN in pharmacology, long-term care, or IV therapy is offered by National Association for Practical Nurse Education and Service (NAPNES) and National Federation for Licensed Practical Nurses (NFLPN). Because of the health care needs of the increasing older adult population and an increased need overall for health care services, the need for LPN/LVNs is expected to grow 25% between 2012 to 2022, which is f aster than the a verage for other occupations (Bureau of Labor Statistics, 2014–15). LPN/LVNs work in child day-care centers, clinics, corrections, home care, hospitals, long-term care, HCP offices, dentist offices, and schools, among other health care settings. Employment of LPN/LVNs is declining in hospitals, but it is growing in settings outside of hospitals. Correctional Nursing A growing clinical setting for the LPN to w ork in is correctional nursing. Local, re gional, and state re gional facilities are interested in hiring LPNs to care for inmates and handle worksite wellness programs for correctional of ficers and Issues in Nursing Practice 27 other staff. Key in this practice area is the ability for the nurse to appropriately apply professional theory , practice, and ethics within the correctional setting. Correctional nurses must possess good physical and mental health and retain sufficient stamina, agility, and visual/auditory acuity necessary to perform all duties associated with LPN practice. In this setting, the LPN must be able to: • Independently implement the nursing process with inmates/ residents in following HCP orders regarding diet, medication and treatments • Utilize knowledge of current medications (actions, interactions, uses, and side effects) • Utilize knowledge of medical, therapeutic, and psychiatric nursing interventions • Appropriately apply quality standards, procedures, and protocols as directed • Be knowledgeable about and sensitive to cultural and socioeconomic differences among the populace as they relate to health and behaviors • Demonstrate an interpersonal skill set that includes high quality oral and written communication skills to facilitate cooperation, pride, trust, and commitment to quality health/medical team communication • Maintain institutional records and provide required institutional reports • Consistently demonstrate medical team professionalism in assessing and providing inmate health care delivery as directed by the HCP • Interview, listen, and provide empathetic assistance to inmates in meeting their needs by carrying out prescribed treatments within the LPN scope of practice • Respond to emergencies as a part of the health care team • Appropriately respond to and seek supervision as needed • Observe, monitor, analyze, and evaluate appropriate quality nursing care, teaching, and treatment • Provide precertification for and coordination of inmates admitted to and discharged from acute care facilities by contributing to and implementing their nursing care plans and routine health tests • Work effectively and efficiently when exposed to difficult or challenging working conditions/situations related to incarcerated patients ETHICS AND VALUES Ethics is a code of values whic h guide our choices and actions and determine the purpose and course of our lives. AYN RAND, RUSSIAN-BORN AMERICAN NOVELIST AND PHILOSOPHER (1905–1982) The study and practice of ethics is grounded in philosophy and dates back to the time of Hippocrates. Ethics is a systematic approach not only to understanding an ethical dilemma but also to e xamining the best outcome for each situation (Butts & Rich, 2013). Bioethics is a branch of ethics that studies moral values in the biomedical sciences and has come to be most closely associated with health care. Today more 4068_Ch03_019-038 15/11/14 12:32 PM Page 28 28 UNIT ONE Understanding Health Care Issues than ever, nurses are confronted with new technological advances mixed in with the challenges of a changing economic climate. These variables often create ethical dilemmas in health care. Morals or morality are also related to ethics, and although the terms ethics and morals are often used interchangeably, morals refers more specifically to personally derived values, beliefs, and behaviors we tend to think of as “right and wrong” or “good and bad” (Butts & Rich, 2013). Values are unwritten standards, ideals, or concepts that give meaning to a person’s life and that often serve as a guide for making decisions and setting priorities in daily life. Although values are commonly derived from societal norms, religion, and family traditions, they can change when a person experiences life-changing events. Value conflicts often occur in everyday life, and people make decisions based on their values. For example, a nurse who values both her career and her family might be forced to decide between going to work or staying home with a sick child. Values exist on many levels. Individuals have personal values that govern their lives and actions. Many groups and organizations have values that represent the group as a whole but may or may not be identical to personal v alues. When a person becomes a member of a group or or ganization, he or she agrees to accept the v alues of the group. Examples of groups include clubs, churches, political parties, and professions. Society as a whole has values. As a member of a society or country, an individual accepts the values of that culture. The values of a profession are usually outlined in a code of ethics. This code is a comprehensi ve set of guidelines that outlines the behavioral expectations for the profession. Ethical issues surround us throughout our lifetime. Bioethical issues are particularly pre valent in our professional li ves for several reasons. To begin with, advances in technology and new treatment options both of fer prolonging or sa ving life. However, in doing so, questions arise related to medical futility such as: Who should receive treatment? How long should treatment continue? Should a patient receive a treatment because it is available, or because it will be effective? How many health care resources should be utilized for the treatment of terminal illnesses? Does quantity or length of life matter more than quality of life? Therefore, it becomes both difficult and important to decide how and when resources will be allocated. Not all bioethical issues mak e headline ne ws. In f act, many ethical dilemmas are regular occurrences in the clinical setting. Research shows that many ethical dilemmas arise related to situations such as inadequate staf fing protection of patients’ rights, unethical practices of HCPs, end-of-life decision making, and breeches in conf identiality (Ulrich et al, 2010). Nurses are in volved in decision making e very day based on the traditional ethical principles of autonomy, beneficence, maleficence, and justice. Have you experienced any of these examples? You are asked to consistently work on a unit that is understaffed. Your charge nurse asks you to “sign her in for the shift” on a regular basis. A patient asks you to keep his prognosis from his spouse.You overhear a coworker who is on break discussing a patient’s status on the telephone, but you do not know who is on the line. Each of these examples prompts questions such as the follo wing: What should be done? What ethical principles are involved? Whose wishes should be honored? An ethical dilemma is a situation in which a person must choose between two options that will af fect the outcome of the case. Although each option can be justif ied as “good,” both have pros and cons. Therefore, when one option is selected or implemented, it creates uncertainty in the outcome of the case (Butts & Rich, 2013). Decision making in the acute care setting is a comple x process involving many members of the health care team.As a result of carrying out orders, nurses must handle consequences that arise from clinical problems. In addition, there is no one-size-fits-all solution for ethical problems. Ev en if dilemmas share a common thread, each has individual influences that make it unique. Potential solutions can appear to be equally good or , worse, equally risky: a promise cannot be kept; information EVIDENCE-BASED PRACTICE Clinical Question How do nurses working in hospital environments experience moral distress? Evidence A systematic review of qualitative literature, using the Joanna Briggs method, found that nurses who experience moral distress experience a wide array of biological, psychological, and stress reactions. In addition, it was found that nurses feel the need to advocate for their patients despite being met with institutional constraints. Finally, it was found that the unequal power structure in institutions contributed to nurses not being able to practice nursing without having their professional values challenged. Implications for Nursing Practice Moral distress is present in clinical practice and has a direct impact on job satisfaction. Institutions should design structures of support for nurses to help lessen the effects of moral distress as well as provide an environment in which nurses can practice that does not violate their core professional values. Education on the effects of moral distress, as well as providing nurses with a way to express ethical concerns would also be helpful. REFERENCE Huffman, D., Rittenmeyer, L. (2012). How professional nurses working in hospital environments experience moral distress: A systematic review. Critical Care Nursing Clinics of North America, 24(1), 91–100. 4068_Ch03_019-038 15/11/14 12:32 PM Page 29 Chapter 3 cannot remain confidential; DNR (do not resuscitate) or ders might not be acceptable for some people. Not all patients should recei ve CPR, e ven those who are young. When patients are conscious, their choices are usually respected, but on occasion, even that premise can be difficult to apply. Often, groups of individuals must work together to resolve a conflict if there is disagreement between an HCP and families, nurses and other HCPs, or among family members. Nurses can experience moral distress as a result of being an integral part of this team. Moral distress can be defined as distress e xperienced when knowing the right thing to do b ut being unable to carry it out because of institutional constraints (Jameton, 1984). More recently , moral distress has been associated with job satisfaction and is one of the reasons that nurses lea ve nursing (de Veer et al, 2013). In response to increasing ethical and moral conflicts in the clinical setting, man y hospitals and f acilities have created an ethics committee that helps address especially difficult cases. The multidisciplinary committee might include nurses, other HCPs such as therapists, social workers, and an ethicist. A basic mastery of several elements enhances your ability to perform competently when bioethical issues arise and decision making is the focus. Understanding the ethical component of your nursing role is the first step. Discovering how your personal v alue set influences your nursing practice is another. Acquiring knowledge about relevant ethical material is also essential. An ethical decisionmaking process is a useful tool for e xamining ethical dilemmas. Together these elements provide a foundation from which you can be gin to e xplore the meaning of bioethics in nursing practice today. For more information about bioethics, visit the Center for Bioethics and Human Dignity at www.cbhd.org. Ethical Obligations and Nursing As a nurse, you are an invaluable member of the health care team, contributing to patient care according to your educational preparation and assigned responsibilities. You are guided by the law and the standards set forth by the profession. A professional code of ethics provides a framework. In addition to practicing within the la w, nurses ha ve ethical obligations related to the la w. First, if the la w is considered unethical or has serious limitations, a basic moral obligation of the nurse is to mak e an effort to change that la w. This might be done indi vidually or through political acti vism guided by professional organizations. Becoming involved in a professional organization is one w ay to help change the laws that govern health care and nursing. Nursing Code of Ethics Some of the major ethical obligations of nursing practice are addressed in a nursing code of ethics.A code of ethics should provide guidance for appropriate decision making based on current laws and professional standards. A code of ethics not only provides a base for professional self-e valuation and reflection but also acts as a tool by which the public can hold Issues in Nursing Practice 29 the profession accountable. As a professional guide for ethical practice, NFLPN has practice standards that include ethical practice and conduct. See www.nflpn.org/practice-standards4web .pdf. NAPNES also has standards of practice for LP/VNs at www.napnes.org. A code does not dictate a particular action, nor is it a legal document, although the code should not be in conflict with the law. The code is not enforced by any organization, and no punishment exists if a nurse fails to adhere to it. A code must be interpreted because it usually contains broad statements, but it does serve as a general guideline for professional ethical issues. Ethical codes are updated to reflect current practice, responsibilities, and obligations set forth by the profession. Building Blocks of Ethics The discipline of ethics, especially health care ethics, provides us with useful tools and kno wledge that can assist us when we encounter difficult situations. An understanding of basic concepts, presented here in the form of ethical principles and ethical theories, helps specifically target the ethical components of the problem. Principles and theories of fer frameworks for ethical problem solving. Ho wever, knowledge about ethics cannot in itself pro vide all of the answers to a problem or dilemma. What such knowledge does do is assist us in focusing on the ethical aspects of each case and possibly prevents escalating ar guments about issues not related to the ethics of the case. Ethical Principles Ethical principles derive from moral theory and ha ve two purposes. The first is to provide some framework for society’s moral conduct. The second is to help us take consistent positions and approaches to moral dilemmas. Ethical principles can be found in many professional codes of conduct and are key components of ethical decision making. The ethical principles widely used when examining bioethical and health care dilemmas include autonomy, beneficence, nonmaleficence, fidelity, veracity, and justice. Given the prominence of these ethical principles in the bioethical literature, a basic under standing of them is necessary. AUTONOMY. According to ethicists (and behaviorists, so- cial scientists, and psychologists), what makes human beings different from nonhumans is that people have dignity based on their ability to choose freely what the y will do with their lives. Autonomy is the right of self-determination, independence, and freedom founded on the notion that humans have value, worth, and moral dignity. Autonomy in health care applies to all people capable of and competent in making health care decisions for themselves. HCPs do not need to agree with another person’ s decisions, but must respect the autonomy of the person making the choice. Paternalism occurs when an HCP tries to prevent patients from making autonomous decisions or decides what is best for patients without re gard for their prefer ences. Autonomy also encompasses the professional’s selfdetermination and freedom. 4068_Ch03_019-038 15/11/14 12:32 PM Page 30 30 UNIT ONE Understanding Health Care Issues There are limitations to autonomy. Typically, these limitations arise when a person’ s autonomy interferes with the rights, health, or well-being of self or others. F or example, patients generally have an autonomous right to make decisions regarding their care and le vel of independence. This autonomous right is guaranteed by federal legislation known as the Patient Self-Determination Act, which can be found at www.nrc-pad.org/images/stories/PDFs/fedaddirectives2a.pdf. However, if a person is no longer capable of self-care upon discharge, a request to live independently will not be granted. A person unable to adequately care for himself cannot li ve alone at the e xpense of his health and well-being. Thus the principle of autonomy cannot be upheld. BENEFICENCE. The principle of beneficence proposes that actions taken and treatments provided will benefit a person and promote welfare (Butts & Rich, 2013). The provision of good care not only means the provision of technologically competent care but also care that respects the patient’ s beliefs, feelings, and wishes, as well as those of their f amily and significant others. A common problem encountered when applying this principle is deciding what is good for someone else. Nonmaleficence is one of the oldest obligations in health care, dating back to the Hippocratic oath (400 B.C.). Nonmaleficence is the obligations to “do no harm” (Butts & Rich, 2013). It is common to hear benef icence and maleficence talked about as being “two sides of the same coin.” HCPs are required to do no harm to their patients either intentionally or unintentionally. In current health care practice, the principle of nonmaleficence may be intentionally violated to produce a greater good in the patient’ s long-term treatment. For example, a patient might undergo a painful and debilitating or disf iguring surgery to remo ve a cancerous growth, thereby avoiding death and prolonging life. By extension, the principle of nonmalef icence also requires a nurse to protect from harm those who are considered vulnerable. Vulnerable groups include children, older adults, and those who are mentally incompetent, unconscious, or too weak or debilitated to protect themselves. NONMALEFICENCE. Maintaining a patient’s privacy and confidentiality is related to fidelity (Fig. 3.6). Privacy and confidentiality may or may not be explicit promises. Nurses are obligated to discuss the patient only under circumstances in which it is necessary to deliver high-quality holistic health care, such as: • When given specific instructions to do so by the patient • When there is the grave possibility of harm to either the patient or others • When legally mandated to do so Maintaining confidentiality also applies to the necessary communication of information through the posting of unit censuses and various schedules for tests, procedures, or special examinations (operating room, physical therapy, radiology), storage and access of patient information in computers, and the transmission of patient information via fax machines. Many people other than direct caregivers have legitimate access to a patient’s chart: faculty members in the course of making student assignments, accrediting agencies, risk managers, quality assurance personnel, insurance companies, and researchers. Each is obligated to maintain patient conf identiality to the extent that concealing information: • Does not compromise mandated reports (communicable diseases or gunshot wounds). • Considers various releases already granted by the patient (such as when insurance information was obtained). • Ensures gathering data in the aggregate without identifying specific patients (research or institutional statistics). Other forms of necessary communication include shiftchange reporting and case conferences. Care must be tak en to hold these information-sharing events in settings where the discussion remains private. FIDELITY. Fidelity is the obligation to be f aithful to commit- ments made to self and others. In health care, fidelity includes faithfulness or loyalty to agreements and responsibilities accepted as part of the practice of nursing. It also means not promising a patient something that one cannot deliver or control. Fidelity is the main support for the concept of accountability, although conflicts in f idelity might arise because of obligations owed to different individuals or groups. For example, nurses have an obligation of f idelity to the patients the y care for to provide the highest quality care possible, as well as an obligation of fidelity to their employing institution to follow its rules and policies. Nurses can have an ethical dilemma when a hospital’s policy on staffing creates a situation that does not allow nurses to provide the quality of care they feel is needed. • WORD • BUILDING • nonmaleficence: non—not + maleficentia—evil doing FIGURE 3.6 Maintaining privacy is a patient right and conveys caring to the patient. 4068_Ch03_019-038 15/11/14 12:32 PM Page 31 Chapter 3 VERACITY. Veracity is the virtue of truthfulness. Within health care, it requires HCPs, whenever possible, to tell the truth and not intentionally deceive or mislead patients. As with other rights and obligations, there are limitations to this virtue. The primary limitation occurs when telling patients the truth would seriously harm their ability to reco ver or when the truth can produce greater illness. This is known as therapeutic privilege and is exercised by HCPs in cases when (1) they are trying to protect patients from heartbreaking news, as in the initial stages of treatment; (2) they do not know the facts, making it better not to answer rather than instill f alse hope; and (3) they state what is true rather than state what is not true (Butts & Rich, 2013). An example of this is when there is a ne w or experimental treatment. HCPs can say that in certain clinical trials, patients benef itted in specif ic ways, but they might not be able to cite all of the possible side ef fects because the treatment has not yet been widely used. Another difficult situation can be created in relation to diagnostic information. Although giving diagnostic information is the responsibility of the HCP or RN, LPN/LVNs sometimes find themselves in situations in which they must deal with patients’ questions. If LPN/LVNs feel uncomfortable about reinforcing explanations given by the HCP or the RN, they might avoid answering patients’ questions directly. However, patients do have a right to know this information. The LPN should inform the HCP or RN of the patient’s request for information, and agency policy on patient information sharing should be followed. JUSTICE. Justice is based on f airness and equality (Butts & Rich, 2013). Concerns for justice can focus on ho w we treat individuals and groups in society (psychologically , socially, legally, and politically), and how we equitably distribute material resources such as health care (distrib utive justice) and burdens (taxes) and the appropriate compensation to those who have been harmed. When a patient makes an appointment for 0900 at an outpatient clinic, the patient expects to be seen by the HCP at the designated time unless an emer gency occurs. Unequal treatment would result if a walk-in patient who has no pressing problem is seen by the HCP in place of the patient with the 0900 appointment, forcing subsequent appointments to be delayed. Distrib ution of material resources can be complex because it involves not only benefits (what we receive), but also burdens (what we may be taxed for but then do not receive). Burdens are not just monetary b ut also include such factors as the unequal participation of individuals in medical research and the sacrifices family members make when caring for individuals with disabilities in the home. USE OF PRINCIPLES. One of the most serious limitations of these principles is the lack of any built-in priority when applying them to an ethical dilemma.Autonomy is not automatically prioritized over justice or beneficence over nonmaleficence. However, these principles are helpful in cate gorizing various preferences and positions when examining a dilemma to clarify positions within it. Working with principles moves the discussion to a focus on ethics rather than on a particular personal viewpoint or feeling. Such a strate gy can also avoid a power struggle between those who simply want to win the argument. Issues in Nursing Practice 31 Here is an e xample of an ethical dilemma. A nurse attempts to support a patient’s refusal of surgery, whereas the surgeon claims that the patient must ha ve surgery to avoid losing a foot. When you shift your thinking to realize that the nurse is arguing the case from the perspective of the patient’s autonomy (self-determination) and the surgeon’s actions are motivated by beneficence (to act in a w ay that benefits the patient), the discussion becomes one based on conflicting principles, rather than conflict between indi viduals. Consequently, the discussion can focus on autonomy and benef icence and their respective rationales. This strategy does not resolve the dilemma but makes it less personal and forces participants to de velop sound, ethical rationales for their solution. Ethical Theories Ethical theories are concepts that are more complete than principles for analyzing ethical dilemmas. Theories are used to explain variables, guide inquiry, and provide a foundation with which to conduct decision making. A brief description of two of the major bioethics theories—utilitarianism and deontology—is provided here. Other theoretical approaches to ethical decision making exist, and theories are often combined to address ethical dilemmas. This section also explores the relationship of theology or religion to bioethics. UTILITARIANISM. Utilitarian theory is grounded in the prem- ise that actions are judged right or wrong based purely on their consequences, and therefore, outcomes are the most important e