Standards of Care and Ethical and Legal Issues
INTRODUCTION
Professional nurses occupy the frontlines of the health care arena. So it is no surprise that they are the part of the health care team patients trust most with their health and welfare. Along with this privilege, nurses carry equal duties of responsibility and accountability to follow ethical principles and standards of care integral to the profession. Greater efforts must be made from within the profession to apply evidence-based research data to daily practice systematically and deliberately, thereby increasing patient safety, improving outcomes, and reducing risk and adverse events. Transformation of the professional culture within the health care system itself would give nurses at the bedside the incentive to join in these efforts as full partners with leaders in health care. Additional measures might include protocol implementation, preceptor performance review, peer review, continuing education, patient satisfaction surveys, and the implementation of risk management techniques. However, in certain instances, either despite or in the absence of such internal mechanisms, claims are made for an alleged injury or alleged malpractice liability. Although the vast majority of claims may be without merit, many professional nurses will have to deal with the unfamiliar legal system. A system of ethical principles and standards of care will be beneficial in such situations. Therefore, it is preferable for the nursing profession to incorporate certain ethical and legal principles and protocols into practice to make sure that the patient receives only safe and appropriate care.
ETHICAL CORE CONCEPTS
Clinical ethics literature identifies four principles and values that are integral to the professional nurse’s practice: the nurse’s ethical duty to respect the patient’s autonomy and to act with beneficence, nonmaleficence, and justice.
Respect for the Individual and Autonomy
Respect for the individual’s autonomy incorporates principles of freedom of choice, self-determination, and privacy.
The professional nurse’s duty is to view and treat each individual as an autonomous, self-determining person with the freedom to act in accordance with self-chosen, informed goals, as long as the action does not interfere or infringe on the autonomous action of another.
Numerous institutions and health care organizations have developed patient rights statements and policies that impact nursing care.
The National League of Nursing (NLN) has developed an Education Competencies Model for all educational levels of nursing, which names the core values as caring, diversity, ethics, excellence, holism, integrity, and patient centeredness.
The American Nurses Association (ANA) has developed and updated a Code of Ethics for Nurses, which states,
“the nurse in all professional relationships practices with compassion with respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
Evidence BaseNational League of Nursing. (2010). The NLN Education Competencies Model. New York: Author.
American Nurses Association. (2001). Code of Ethics for Nurses with Interpretive Statements (Code for Nurses). Silver Spring, MD: Author.
Beneficence
The principle of beneficence affirms the inherent professional aspiration and duty to help promote the well-being of others and, often, is the primary motivating factor for those who choose a career in the health care profession. Health care professionals aspire to help people achieve a better life through an improved state of health.
Nonmaleficence
The principle of nonmaleficence complements beneficence and obligates the professional nurse not to harm the patient directly or with intent.
In the health care profession, this principle is actualized only with the complementary principle of beneficence because it is common for the nurse to cause pain or expose the patient to risk of harm when such actions are justified by the benefits of the procedures or treatments.
It is best to seek to promote a balance of potential riskinduced harms with benefits, with the basic guideline being to strive to maximize expected benefits and minimize possible harms. Therefore, nonmaleficence should be balanced with beneficence.
Justice
Justice, or fairness, relates to the distribution of services and resources.
As the health care dollar becomes increasingly scarce, justice seeks to allocate resources fairly and treat patients equally.
Dilemmas arise when resources are scarce and insufficient to meet the needs of everyone. How do we decide fairly who gets what in such situations?
One might consider whether it is just or fair for many people not to have funding or access to the most basic preventive care, whereas others have insurance coverage for expensive and long-term hospitalizations.
Along with respect for people and their autonomy, the complex principle of justice is a culturally comfortable principle in countries such as the United States. Nonetheless, the application of justice is complex and often challenging.
ETHICAL DILEMMAS
Conflicting Ethical Principles
Ethical dilemmas arise when two or more ethical principles are in conflict.
Such dilemmas can best be addressed by applying principles on a case-by-case basis once all available data are gathered and analyzed.
Clinicians should network with their colleagues and consider establishing multidisciplinary ethics committees to provide guidance.
Ethics Committees
Ethics committees identify, examine, and promote resolution of ethical issues and dilemmas by:
Protecting the patient’s rights.
Protecting the staff and the organization.
Reviewing decisions regarding clinical practice and standards of practice.
Improving the quality of care and services.
Serving as educational resources to staff.
Building a consensus on ethical issues with other professional organizations.
Addressing and resolving ethical dilemmas is usually a challenging decision shared with the clinical staff.
Examples of Ethical Dilemmas and Possible Responses
Unsafe Nurse-to-Patient Ratio
A pattern of unsafe nurse-to-patient ratio can be caused by temporary or long-term staffing problems.
A series of actions to best resolve the problem includes:
Address this unsafe situation verbally and in writing to the unit charge nurse with copies to the nursing supervisor and director of nursing.
This will likely prompt action by the facility, such as creating an as-needed pool of nurses to call for such situations, hiring more staff, or, in the interim, securing contracts with outside nursing agencies and utilizing agency nursing personnel.
Tolerance by staff nurses employed under such circumstances will preclude appropriate resolution and will leave the nurse open to unsafe practice and unmet patient needs, potentially increasing the risk of liability.
Although the employer is liable for the acts of the employee performed within the scope of employment, the nurse will not be exonerated should a patient’s care be compromised in a setting of an unsafe nurse-to-patient ratio.
Nonresponse by Physician
A patient arrives to the rehabilitation unit at 9 PM with numerous positive criteria for falling, including poor short-term memory, daily use of a diuretic, daily use of a sleep aid, a history of a fall within the preceding 2 months, and known vision impairment.
Patient is oriented to time, place, and person, his new room, facility bed, and call light use.
The nurse instructs patient to summon her if he needs to void or otherwise get out of bed, at least until he becomes familiar with his new environment.
Upon returning to patient’s room 10 minutes later, the nurse finds patient out of bed, arranging his clothes in his closet, standing in a pool of urine on the floor.
The nurse weighs the risks and benefits of restraint use and determines whether alternatives are available. She calls the physician for a restraint order if patient continues to jeopardize his safety. The nurse intends to ask the physician for an order with clear specification of the least restrictive method of restraint, the duration, circumstances, frequency of monitoring, and reevaluation if it differs from facility policy. However, the physician does not return her calls.
The nurse documents her initial assessment of the patient, her nursing diagnoses, the orientation to room and equipment provided to the patient, the circumstances wherein she found the patient out of bed, and her repeated messages for the physician and the lack of a return telephone call.
Again, a series of actions may resolve the problem or at least prevent injury to the patient. Address this situation with intermediate measures while waiting for the physician’s return call:
Raise side rails on the patient’s bed.
Move patient to a room close to the nurse’s station.
Place a sign on patient’s room door and above the bed identifying him as being at risk for falling.
Place a sign above the bed instructing personnel to raise the bed’s side rails fully before leaving patient’s room.
Check on the patient frequently during the first 24 hours, reminding him of the call light, its use, and the need to call the nurse before getting out of bed.
Call the patient’s family, advising them of your concern about the patient’s safety, and discuss the issue of restraints with them. Discuss the risk for falling and prevention of fall-induced injury versus the restriction of the patient’s freedom of movement about the room.
Document ongoing assessments of potential problems, calls to the physician, and discussions with family members.
Apply restraints according to the policy of the rehabilitation unit until an order is secured from the physician.
Consult facility policy on restraint use.
Secure an order from the physician for restraints to be used as needed, including specific criteria outlined in step 1d.
Reassess the patient’s need for diuretic and sleep aid or sedative use. Discuss discontinuation of any unnecessary medications that increase the patient’s degree of confusion or risk for falling, if possible.
Inappropriate Orders
A 65-year-old patient with a diagnosis of uncontrolled heart failure is presently in the intensive care unit for treatment and hemodynamic monitoring. He is becoming increasingly anxious during your shift, but vital signs are stable and respiratory distress is absent. A house officer is summoned to evaluate this change in clinical status.
The house officer, unfamiliar with the patient, spends 2 minutes reviewing the chart, examines the patient for 2 minutes, and orders a sedative to be administered stat and, as needed, every 4 hours.
You tell the house officer that you heard decreased breath sounds in the left, lower lung and ask him to order some diagnostic tests, such as a chest x-ray and arterial blood gas analysis, and share your concern that administering a sedative to the patient may mask the underlying cause of the anxiety, lead to respiratory compromise, and delay diagnosis and treatment of the underlying clinical problem. Nevertheless, he leaves the unit.
You decide not to give the sedative ordered by the house officer.
Although you cannot automatically follow an order you think is unsafe, you cannot just ignore a medical order either.
Document the scenario described above in the patient’s chart, contact the resident on call, and notify your supervising nurse.
If assessment by the resident on call agrees with the house officer, call the attending physician, discuss your concerns with him, obtain appropriate stat orders, and notify the house officer and resident of the attending physician’s orders and the actions you took.
Notify all involved medical and nursing personnel of the patient’s status.
Document clearly, succinctly, and in a timely fashion.
Your actions reflect concern about the best interest of the patient and, although they may yield negative behaviors by the house officer or resident, it is more important to prevent potential injury to the patient.
LEGAL ASPECTS OF PROFESSIONAL NURSING PRACTICE
Accountability
Integral to the practice of any profession is the inherent need to be responsible for actions taken and for omissions.
The professional nurse must be proactive and take all appropriate measures to ensure that her own practice is not lacking, remiss, or deficient in any area or way.
Useful proactive measures include:
Maintaining familiarity of relevant, current facility policies, procedures, and regulations as they apply to the nurse’s practice and specialty area.
Providing for self-audit.
Providing for peer review to assess reasonableness of care in a particular setting for a particular problem.
Working with local nursing organizations to make certain that local standards of practice are met.
Examining the quality (accuracy and completeness) of documentation.
Establishing open working relationships with colleagues wherein honest constructive criticism is welcomed for the greater goal of quality patient care.
Local standards of practice normally coordinate with those of nationally accepted standards.
Advocacy
The professional nurse has the duty to:
Promote what is best for the patient.
Ensure that the patient’s needs are met.
Protect the patient’s rights.
Confidentiality
The patient’s privacy is consistent with the Hippocratic Oath and with the law as part of the constitutional right to privacy.
Although the professional nurse should assure the patient of confidentiality, limits on this standard must be clarified and discussed with the patient at the earliest opportunity.
It is imperative to clearly understand the process of informed consent and the legal standard for disclosure of confidential patient information to others.
The Medical Record Confidentiality Act of 1995, a federal statute, is the primary federal law governing the use of health treatment and payment records. Several practical guidelines include:
Respecting the individual’s right to privacy when requesting or responding to a request for a patient’s medical records.
Always requiring a signed medical authorization and consent form to release medical records and information to protect and respect patient-provider privilege statutes.
Discussing confidentiality issues with the patient and establishing consent. Addressing concerns or special requests for information not to be disclosed.
Based on the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services issued guidelines in 2000 to protect the confidentiality of individually identifiable health information. The rule:
Limits the use and disclosure of certain individually identifiable health information.
Gives patients the right to access their medical records.
Restricts most disclosure of health information to the minimum needed for the intended purpose.
Establishes safeguards and restrictions regarding the use and disclosure of records for certain public responsibilities, such as public health, law enforcement, and research.
Provides for criminal or civil sanctions for improper uses or disclosures.
The exceptions or limits to confidentiality include situations in which society has judged that the need for information outweighs the principle of confidentiality. However, legal counsel should be consulted because these decisions are made on a case-by-case basis and broad generalizations cannot be assumed.
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