LEARNING EXERCISE 6.3
advocating for a transgendered patient
You are the charge nurse on a medical unit. Today, during walking rounds, a transgendered patient tells you that she hears the staff whispering and making fun of her in the hallway outside her room. She says this is hurtful and that while the staff may lack clarity about her gender identity, she does not, and that becoming a woman is all she ever wanted. She said that friends who have come to visit her have also been made to feel uncomfortable.
assignment:
1. How best can you advocate for this patient?
2. What leadership roles could you employ to address the lack of compassion and advocacy for this patient with the staff?
3. What policies should be created to assure compliance with the Department of Health and Human Services mandate to protect the visitation rights of this patient’s friends and significant others?
There has also been significant progress in patient rights related to the privacy of health- care information, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In addition, new legislation—The American Recovery and Reinvestment Act of 2009 (ARRA)—maintains and expands HIPAA guidelines as they are related to patient health information privacy and security protections.
States have also created bills of rights. In 1994, the Illinois General Assembly established a Medical Patient Rights Act that established certain rights for medical patients and provided a penalty for violations of these rights (Illinois General Assembly, n.d.). California has adopted a similar Patient Guide pertaining to health-care rights and remedies (see Display 6.4). These guidelines, however, are not legally binding, although they may influence federal or state funding and certainly should be considered professionally binding.
Some legally binding legislation has been passed, however, to safeguard vulnerable populations. One such legislation, the Genetic Information and Nondiscrimination Act (GINA), was passed in 2008, making it illegal for health insurers or employers to discriminate against individuals based on their genetic information (Becze, 2011). GINA applies to all
employers regardless of the number of employees, unlike the Affordable Care Act which is only for employers with more than 15 employees. However, it does not protect an individual from discrimination based on genetic information when qualifying for life, disability, and long-term care insurance (Becze).
Other countries have passed legally binding legislation as well. The Deprivation of Liberty Safeguards and Mental Capacity Act was legislated in the United Kingdom in 2005, providing some protection for residents in care homes who are at risk for being deprived of their liberties through a whole host of interventions, including the use of physical restraints and even locked doors (Goodall, 2012). The act requires that deprivation of liberty safeguards be in place through the use of standard or urgent authorization processes so that when the deprivation of liberty must occur, it is in the best interest of the resident.
Similarly, mental health patients who are involuntarily admitted to hospitals in Alberta, Canada, are afforded some legal protections, including the Mental Health Act of Alberta (Orr, 2013). This act provides the authority, protocols, and timelines for admitting, detaining, and treating persons with serious mental disorders.
In accordance with section 70707 of the California Administrative Code, the hospital and medical staff have adopted the following list of patient rights to:
1. Exercise these rights without regard to sex; cultural, economic, educational, or religious back- ground; or the source of payment for care.
2. Considerate and respectful care.
3. Knowledge of the name of the physician who has primary responsibility for coordinating care and the names and professional relationships of other physicians who will see the patient.
4. Receive information from the physician about illness, course of treatment, and prospects for recovery in terms the patient can understand.
5. Receive as much information about any proposed treatment or procedure as the patient may need to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically signifi- cant risks involved in this treatment, alternate course of treatment or nontreatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.
6. Participate actively in decisions regarding medical care. To the extent permitted by law, this includes the right to refuse treatment.
7. Full consideration of privacy concerning medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be advised of the reason for the presence of any individual.
8. Confidential treatment of all communications and records pertaining to the patient’s care and stay in the hospital. Written permission shall be obtained before medical records are made avail- able to anyone not directly concerned with the patient’s care.
9. Reasonable responses to any reasonable requests for service.
10. Ability to leave the hospital even against the advice of the physician.
11. Reasonable continuity of care and to know in advance the time and location of appointment and the physician providing care.
12. Be advised if hospital/personal physician proposes to engage in or perform human experimentation affecting care or treatment. The patient has the right to refuse to participate in such research projects.
13. Be informed by the physician or a delegate of the physician of continuing health-care require- ments following discharge from the hospital.
14. Examine and receive an explanation of the bill, regardless of source of payment.
15. Know which hospital rules and policies apply to the patient’s conduct.
16. Have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding medical care on behalf of the patient.
Source: Prepared by Consumer Watchdog (n.d.) and available at http://www.calpatientguide.org/index.html
DISpLAy 6.4 List of patient rights in california
The bottom line is that patients are increasingly aware that they have rights, and as a result, they are more assertive and involved in their health care. They want to know and understand their treatment options and to be participants in decisions about their health care. This right to information and participation in medical care decisions has led to some conflicts in the areas of informed consent and access to medical records. Leader-managers, however, have a responsibility to see that all patient rights are met, including the right to privacy and personal liberty, which are guaranteed by the constitution.
SUBORDINATE AND WORKpLACE ADVOCACy
Subordinate advocacy is a neglected concept in management theory but is an essential part of the leadership role. Standard 16 of the ANA Scope and Standards for Nursing Administration (2009) suggests that nurse administrators should advocate for other health-care providers (including subordinates) as well as patients, especially when this is related to health and safety.
For example, workplace advocacy is a critical role managers assume to promote subordinate advocacy. In this type of advocacy, the manager works to see that the work environment is both safe and conducive to professional and personal growth for subordinates.
Unfortunately, workplace violence is an ever increasing problem in contemporary society.
The Occupational Safety and Health Administration (OSHA) reports that over 2 million American workers are victims of workplace violence each year and the second leading cause of death from women while at work is workplace homicides from assaults and other violent acts (Papa & Venella, 2013).
Survey results from a descriptive study of experiences of 3,465 registered nurse members of the Emergency Nurses Association noted that approximately 25% of the respondents had experienced physical violence greater than 20 times in the previous 3 years and nearly 20% reported encountering verbal abuse more than 200 times in that same time frame.
Respondents suggested these incidents were often not reported due to fear of retaliation and fear of a lack of support from their employer. The researchers concluded that one factor important to mitigating this type of workplace violence then is a commitment by upper management to ensuring a safer workplace by hospital administrators, emergency department managers, and hospital security.
In addition, occupational health and safety must be assured by interventions such as reducing worker exposure to workplace violence, needle sticks, or blood and body fluids.
Subordinates should also be able to have the expectation that their work hours and schedules will be reasonable, that staffing ratios will be adequate to support safe patient care, that wages will be fair and equitable, and that nurses will be allowed participation in organizational decision making. When these working conditions do not exist, managers must advocate to higher levels of the administrative hierarchy to correct the problems.
In addition, when the health-care industry has faced the crisis of inadequate human resources and nursing shortages, many organizations have made quick, poorly thought-out decisions to find short-term solutions to a long-term and severe problem. New workers have been recruited at a phenomenally high cost, yet the problems that caused high worker attrition were not solved. Upper-level managers must advocate for subordinates in solving problems and making decisions about how best to use limited resources. These decisions must be made carefully, following a thorough examination of the political, social, economic, and ethical costs.
Another way leaders advocate for subordinates is in creating a work environment that promotes risk taking and leadership. For example, administrators should foster work environments that promote subordinate empowerment so that workers have the courage to speak up for patients, themselves, and their profession. In addition, managers must help members of their health-care team resolve ethical problems and live with the solutions at the unit level.
The following are suggestions for creating an environment that promotes subordinate advocacy:
• Invite collaborative decision making.
• Listen to staff needs.
• Get to know staff personally.
• Take time to understand the challenges faced by the staff in delivering care.
• Face challenges and solve problems together.
• “Go to bat” for staff when needed.
• Promote shared governance.
• Empower staff.
• Promote nurse autonomy.
• Provide staff with workable systems.
Managers must recognize what subordinates are striving for and the goals and values that subordinates consider appropriate. The leader-manager should be able to guide subordinates toward actualization while defending their right to autonomy. To help nurses deal with ethical dilemmas in their practice, nurse-managers should establish and utilize appropriate support groups, ethics committees, and channels for dealing with ethical problems.