Conclusion
DISPLAY 6.5 List of Patient Rights in California
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 background; 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 significant 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 available 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 requirements 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: Consumer Watchdog. (n.d.). The California patient’s guide. Your health care rights and remedies. Retrieved March 8, 2016, from http://www.calpatientguide.org/index.html
Some legally binding legislation has been passed, however, to safeguard vulnerable populations. One such legislation, the Genetic Information and Nondiscrimination Act (GINA), is a federal law passed in 2008, making it illegal for health insurers or employers to discriminate against individuals based on their genetic information (Genetics Home Reference, 2016).
Genetics Home Reference (2016) notes that
the law has two parts: Title I, which prohibits genetic discrimination in health insurance, and Title II, which prohibits genetic
discrimination in employment. Title I makes it illegal for health insurance providers to use or require genetic information to make decisions about a person’s insurance eligibility or coverage. This part of the law went into effect on May 21, 2009. Title II makes it illegal for employers to use a person’s genetic information when making decisions about hiring, promotion, and several other terms of employment.
This part of the law went into effect on November 21, 2009. (para. 2–3)
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 from unneeded use of physical restraints and other loss of liberties. 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. This act provides the authority, protocols, and timelines for admitting, detaining, and treating persons with serious mental disorders.
LEARNING EXERCISE
6.4
How Can You Best Advocate?
Y
ou are a unit supervisor in a skilled nursing facility. One of your aides, Martha Greenwald, recently reported that she suffered a “back strain” several weeks ago when she was lifting an elderly patient. She did not report the injury at the time because she did not think it was serious. Indeed, she finished the remainder of her shift and has performed all of her normal work duties since that time.Today, Martha reports that she has just left her physician’s office and that he has advised her to take 4 to 6 weeks off from work to fully recover from her injury. He has also prescribed physical therapy and electrical nerve stimulation for the chronic pain. Martha is a relatively new employee, so she has not yet accrued enough sick leave to cover her absence. She asks you to complete the paperwork for her absence and the cost of her treatments to be covered as a work-related injury.
When you contact the workers’ compensation case manager for your facility, she states that the claim will be investigated; however, with no written or verbal report of the injury at the time it occurred, there is great likelihood that the claim will be rejected.
A S S I G N M E N T:
How best can you advocate for this subordinate?
The Right to Die Movement and Physician-Assisted Suicide
At times, individual rights must be superseded to ensure the safety of all parties involved. It is important, however, for the patient advocate to know the difference between controlling patient choices and assisting patients to choose. Health-care professionals often have knowledge that patients do not have but must be careful not to use paternalism at the cost of patient autonomy.
It is important for the patient advocate to be able to differentiate between controlling patient choices (domination and dependence) and in assisting patient choices (allowing freedom).
For example, the right to die movement has gained momentum the past decade. In 1997, Oregon became the first state to allow terminally ill people to receive lethal doses of medication from their doctors. By early 2016, three other states had followed suit (Washington, Vermont, and California), and Montana allowed it by court decision (Death with Dignity, 2016). Multiple other states are considering legislation for physician- assisted suicide (PAS) as well.
Typically, right to die laws apply only to patients who are at least 18 years old, with the capacity to make medical decisions, with a terminal disease expected to result in death within 6 months. The California End of Life Option Act requires the patient to make two verbal requests at least 15 days apart and one written request that is signed, dated, and witnessed by two adults (McGreevy, 2016). The patient may rescind the request for an aid-in-dying drug at any time and in any manner and a request for a prescription cannot be made on behalf of a patient through an agent under a power of attorney, an advance health-care directive, a conservator or any other person (McGreevy, 2016). Once the prescription is filled, the patient must complete a “Final Attestation for an Aid-in-Dying Drug to End My Life in a Humane and Dignified Manner” form within 48 hours before self-administering the drug. Although the law is silent as to what cause of death should be identified on the death certificate, it does say taking an aid-in-dying drug “shall not constitute suicide” (McGreevy, 2016).
Debates, however, around the impetus for and ethics of PAS continue to rage. Although many proponents characterize the action as a liberation from suffering, opponents suggest that advances in pain control and hospice care could address many of the issues driving terminally ill patients to seek PAS (McGreevy, 2016).
Physicians do have the legal right to choose whether they will participate in PAS. “A healthcare provider who refuses to participate in activities under the act on the basis of conscience, morality or ethics cannot be subject to censure, discipline . . . or other penalty by a healthcare provider, professional association or
organization” (McGreevy, 2016, para. 19). Physicians who do participate are protected from criminal, civil, and administrative liability if they follow the requirements.
Casey Gallagher (2016) notes, however, that helping patients make decisions about PAS, and supporting them in their choices, is difficult even when impending death is a certainty. “All anyone can do is guarantee each individual the freedom of decision and to determine what he or she deems best for his or her own body or mental well-being” (Casey Gallagher, 2016, para. 5).
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. Leader-managers 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 (2009) Scope and Standards for Nursing Administration 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. For example, managers should assure that Occupational Safety and Health Administration (OSHA) guidelines for worker safety are followed. For example, educating staff about proper body mechanics and assuring that staffing is adequate for safely ambulating and turning patients can reduce the incidence of back injuries in health-care workers. In addition, occupational health and safety must be assured by interventions such as reducing worker exposure to workplace violence,
needlesticks, or blood and body fluids. When these working conditions do not exist, managers must advocate to higher levels of the administrative hierarchy to correct the problems.
In addition, workplace advocacy is needed to address workplace violence: an ever increasing problem in contemporary society. 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 (Papa & Venella, 2013). 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.
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 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 work
effectively with 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.
Support staff as 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.
Whistleblowing as Advocacy
The public has become much more aware of ethical malfeasance within its institutions and corporate organizations as a result of various scandals that have occurred in the last 50 years. From Watergate to Morgan Stanley to Bernard Madoff’s Ponzi scheme, the American public has been fed a diet of wrongdoing that has led to an increase in moral awareness.
LEARNING EXERCISE
6.5
Write It Down. What Would You Change?
L
ist five things that you would like to change about nursing or the health-care system. Prioritize the changes that you have identified. Write a one-page essay about the change that you believe is most needed.Identify the strategies that you could use individually and collectively as a profession to make the change happen. Be sure that you are realistic about the time, energy, and fiscal resources you have to implement your plan.
Wrongdoing does not stop at large corporations or political activity, it also occurs within health-care organizations. Huston (2017c) suggests that in an era of managed care, declining reimbursements and the ongoing pressure to remain fiscally solvent, the risk of fraud, misrepresentation, and ethical malfeasance in health-care organizations has never been higher. As a result, the need for whistleblowing has also likely never been greater.
Huston (2017c) also suggests that there are basically two types of whistleblowing. Internal whistleblowing occurs within an organization, reporting up the chain of command. External whistleblowing involves reporting outside the organization such as the media and an elected official. An example of whistleblowing by a health- care provider might be to report inflated practices of documentation and coding that result in elevated cost reimbursement.
Huston (2017c) notes that nurses as health-care professionals have a responsibility to uncover, openly discuss, and condemn shortcuts, which threaten the clients they serve. It is important, however, to remember that whistleblowing should never be considered the first solution to ethically troubling behavior. Indeed, it should be considered only after other prescribed avenues of solving problems have been attempted. This is true, however, only if patients’ lives are not at stake. In those cases, immediate action must be taken.
In addition, the employee should typically go up the chain of command in reporting his or her concerns.
This process, however, must be modified when the immediate supervisor is the source of the problem. In such a case, the employee might need to skip that level to see that the problem is addressed. Indeed, Petry, Penman, and Foose (2015) noted that most would rather raise the issue internally to their manager than take it outside.
Thus, companies generally get the opportunity to resolve issues internally—the question is whether they will take this opportunity or miss it.
There are other general guidelines for blowing the whistle that should also be followed, including carefully documenting all attempts to address the problem and being sure to report facts and not personal
interpretations. These guidelines, as well as others, are presented in Display 6.6.