To See or Not to See
For the last few days, you have been taking care of Mr. Cole, a 28-year-old patient with end- stage cystic fibrosis. You have developed a caring relationship with Mr. Cole and his wife. They are both aware of the prognosis of his disease and realize that he has only a short time left to live.
When Dr. Jones made rounds with you this morning, she told the Coles that Mr. Cole could be discharged today if his condition remains stable. They were both excited about the news because they had been urging the doctor to let him go home to enjoy his remaining time surrounded by things he loves.
When you bring in Mr. Cole’s discharge orders to his room in order to review his medications and other treatments, you find Mrs. Cole assisting Mr. Cole as he coughs up bright red blood. When you confront them, they both beg you not to tell the doctor or chart the incident because this is the first time this has happened. They believe that it is their right to go home and let Mr. Cole die surrounded by his family. They said that they know that they can leave against their physician’s wishes and go home AMA (against medical advice), but if they do, their insurance will not pay for home care.
Assignment: What is your duty in this case? What are Mr. Cole’s rights? Is it ever justified to withhold information from the physician? Will you chart the incident and will you report it to anyone? Solve this case, justifying your decision by using ethical principles.
REFERENCES
Alichnie, C. (2012). Ethics and nursing. Pennsylvania Nurse, 67(2), 5–26.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC:
American Nurses Publishing.
American Nurses Association. (2009). Nursing administration: Scope and standards of practice. Silver Springs, MD: American Nurses Publishing.
Bitoun Blecher, M. (2001–2013). What color is your whistle? Minoritynurse.com. Retrieved February 24, 2013, from http://www.minoritynurse.com/
workplace-issues/what-color-your-whistle Crisham, P. (1985). MORAL: How can I do what is right?
Nursing Management, 16(3), 42A–42N.
Davis, S., Schrader, V., & Belcheir, M. (2012). Influencers of ethical beliefs and the impact on moral distress and conscientious objection. Nursing Ethics, 19(6), 738–749.
Gallagher, A., & Hodge, S. (Eds.) (2012). Ethics, law and professional issues: A practice-based approach for health professionals. Basingstoke: Palgrave MacMillan.
Grob, C., Leng, J., & Gallagher, A. (2012). Educational responses to unethical healthcare practice. Nursing Standard, 26(41), 35–41.
Kearney, G., & Penque, S. (2012). Ethics of everyday decision making. Nursing Management – UK, 19(1), 32–36.
Mortell, M. (2012). Hand hygiene compliance: Is there a theory-practice-ethics gap? British Journal of Nursing, 21(17), 1011–1014.
Nalley, C. (2013, February 8). Moral distress takes toll on nurses. Advance for nurses. Retrieved February 25, 2013, from http://nursing.advanceweb.com/Features/
Articles/Moral-Distress-Takes-Toll-on-Nurses.aspx Pauly, B. M., Varcoe, C., & Storch, J. (2012, March).
Framing the issues. Moral distress in health care.
HEC Forum, 24(1), 1–11.
Silén, M., Kjellström, S., Christensson, L., Sidenvall, B.,
& Svantesson, M. (2012). What actions promote a positive ethical climate? A critical incident study of nurses’ perceptions. Nursing Ethics, 19(4), 501–512.
Sorbello, B. (2008, December). The nurse administrator as caring person: A synoptic analysis applying caring philosophy, Ray’s ethical theory of existential authenticity, the ethic of justice, and the ethic of care.
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Woods, M. (2012). Exploring the relevance of social justice within a relational nursing ethic. Nursing Philosophy, 13(1), 56–65.
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Legal and Legislative Issues
… It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.
—Florence Nightingale
… Laws or ordinances unobserved, or partially attended to, had better never have been made.
—George Washington, letter to James Madison, March 31, 1787
CROSSWALK
this chapter addresses:BSN Essential II: Basic organizational and systems leadership for quality care and patient safety BSN Essential V: health-care policy, finance, and regulatory environments
BSN Essential VIII: professionalism and professional values MSN Essential II: Organizational and systems leadership MSN Essential VI: health policy and advocacy
AONE Nurse Executive Competency II: a knowledge of the health-care environment AONE Nurse Executive Competency V: Business skills
QSEN Competency: safety
LEARNING OBJECTIVES
The learner will:l correlate the legal authority of nursing practice and the nursing process
l select appropriate legal nursing actions in sensitive clinical situations
l explain how increased consumer awareness of patient rights has affected the actions of the health-care team
l evaluate the significance of professional and institutional licensure
l describe appropriate methods of ensuring informed consent
l analyze the impact of civil law on nursing practice
l differentiate between legal and ethical accountability
5
Chapter 4 presented ethics as an internal control of human behavior and nursing practice.
Therefore, ethics has to do with actions that people should take, not necessarily actions that they are legally required to take. On the other hand, ethical behavior written into law is no longer just desired, it is mandated. This chapter focuses on the external controls of legislation and law. Since the first mandatory Nurse Practice Act was passed in North Carolina in 1903, nursing has been legislated, directed, and controlled to some extent.
The primary purpose of law and legislation is to protect the patient and the nurse. Laws and legislation define the scope of acceptable practice and protect individual rights. Nurses who are aware of their rights and duties in legal matters are better able to protect themselves against liability or loss of professional licensure.
This chapter has five sections. The first section presents the primary sources of law and how each affects nursing practice. The nurse’s responsibility to be proactive in establishing
and revising laws affecting nursing practice is emphasized. The second section presents the types of legal cases in which nurses may be involved and differentiates between the burden of proof and the consequences for each if the nurse is found to have broken the law. The third section identifies specific doctrines used by the courts to define legal boundaries for nursing practice. The role of state boards in professional licensure and discipline is examined. The fourth section deals with the components of malpractice for the individual practitioner and the manager or supervisor. Legal terms are defined. The fifth and final section discusses issues such as informed consent, medical records, intentional torts, the Patient Self-Determination Act (PSDA), the Good Samaritan Act, and the Health Insurance Portability and Accountability Act (HIPAA).
This chapter is not meant to be a complete legal guide to nursing practice. There are many excellent legal textbooks and handbooks that accomplish that function. The primary function of this chapter is to emphasize the widely varying and rapidly changing nature of laws and the responsibility that each manager has to keep abreast of legislation and laws affecting both nursing and management practice. Leadership roles and management functions inherent in legal and legislative issues are shown in Display 5.1.
DISpLAy 5.1 Leadership Roles and Management Functions Associated with Legal and Legislative Issues
LEADERSHIP ROLES
1. serves as a role model by providing nursing care that meets or exceeds accepted standards of care.
2. Updates knowledge and skills in the field of practice and seeks professional certification to increase expertise in a specific field.
3. reports substandard nursing care to appropriate authorities following the established chain of command.
4. Fosters nurse–patient relationships that are respectful, caring, and honest, thus reducing the possibility of future lawsuits.
5. creates an environment that encourages and supports diversity and sensitivity.
6. prioritizes patient rights and patient welfare in decision making.
7. demonstrates vision, risk taking, and energy in determining appropriate legal boundaries for nursing practice, thus defining what nursing is and what should be in the future.
MANAGEMENT FUNCTIONS
1. increases knowledge regarding sources of law and legal doctrines that affect nursing practice.
2. delegates to subordinates wisely, looking at the manager’s scope of practice and that of the individuals he or she supervises.
3. Understands and adheres to institutional policies and procedures.
4. Minimizes the risk of product liability by assuring that all staff are appropriately oriented to the appropriate use of equipment and products.
5. Monitors subordinates to ensure they have a valid, current, and appropriate license to practice nursing.
6. Uses foreseeability of harm in delegation and staffing decisions.
7. increases staff awareness of intentional torts and assists them in developing strategies to reduce their liability in these areas.
8. provides educational and training opportunities for staff on legal issues affecting nursing practice.