exam 3 rn 112

In the Business and Professions code, Title 16, #1445, the Standards of Competent Performance are described:

1443.5. Standards of Competent Performance A registered nurse shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: (1) Formulates a nursing diagnosis through observation of the client's physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team. (2) Formulates a care plan, in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures. (3) Performs skills essential to the kind of nursing action to be taken, explains the health treatment to the client and family and teaches the client and family how to care for the client's health needs. (4) Delegates tasks to subordinates based on the legal scopes of practice of the subordinates and on the preparation and capability needed in the tasks to be delegated, and effectively supervises nursing care being given by subordinates. (5) Evaluates the effectiveness of the care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and health team members, and modifies the plan as needed. (6) Acts as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided. Here is an example of a situation where an R.N. did not follow the standards of competent performance and was disciplined by the B.R.N.: On or about July 20, 2007, Respondent worked during the night shift as a registered nurse at Waters Edge Nursing Home in Alameda, California. During the course of her shift, Respondent was required to administer medications to patients. During the course of the night, Respondent administered the wrong medication to patient A. Respondent administered Keflex to patient A, despite the fact that said medication had not been ordered for this patient, and despite the fact that patient A informed Respondent that she was not taking Keflex, and despite the fact that patient A was wearing an identification bracelet at the time. During the course of the night, Respondent administered the wrong medication to patient B. Respondent administered Levothyroxine to patient B, despite the fact that said medication had not been ordered for this patient, and despite the fact that patient B was wearing an identification bracelet at the time. (http://www.rn.ca.gov/public/rn189995.pdf) 2. Employee. The second legal role is that of employee. A nurse who is employed by a hospital works as an agent of the hospital, and the nurse's contract with patients is an implied one. The nurse employed by a hospital functions within an employer-employee relationship in which the nurse represents and acts for the hospital and therefore must function within the policies of the employing agency. The nurse is protected when following the employing agency's policies and procedures. This type of legal relationship creates the ancient legal doctrine known as respondeat superior. The employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee. Note: This doctrine does not imply that the nurse cannot be held liable as an individual. Nor does it imply that the doctrine will prevail if the employee's actions are extraordinarily inappropriate. Nurses can be held liable for criminal acts and for failure to act as well. 3. Citizen. The third legal role of the nurse is that of citizen. The rights and responsibilities of the nurse in the role of citizen are the same as those of any individual under the legal system. However, one legal protection for nurses is the Good Samaritan Act. According to California's Good Samaritan Act, 2727.5. Liability for emergency care A person licensed under this chapter who in good faith renders emergency care at the scene of an emergency which occurs outside both the place and the course of that person's employment shall not be liable for any civil damages as the result of acts or omissions by that person in rendering the emergency care. This section shall not grant immunity from civil damages when the person is grossly negligent.(California Business and Professions Code, #2727.5)

A lawsuit for malpractice must prove 4 things:

• The nurse had a duty to provide care to the patient and to follow an acceptable standard of care. • The nurse failed to follow the standard of care. • The nurse's failure to follow the standard of care caused the patient's injuries. • The patient suffered damage as a result of the nurse's actions. So, pretend that I am your patient and you forget to raise the side rails of my bed after giving me a sleeping pill. I try to get up while I'm sleepy and fall out of bed, breaking my hip. Does this situation meet the 4 requirements above?

Study Questions: 1. Why can't a person who has received a sedative sign a consent? 2. In what situation is it acceptable for the patient to sign a consent with an "X" 3. What should be done if the patient speaks only Farsi and the physician speaks only English?

1. cause people under sedation are not considered oriented x4 2. can't read/write 3. get a hospital/official translator

Describe the role of the nurse advocate in health care.

A patient advocate is one who looks out for the patient's interests, who acts on his behalf and protects his rights. What are the patient's rights and responsibilities? Read about them in Kozier, p. 94

Explain the nurse's role in obtaining informed consent.

A patient signs a general consent form when he is admitted to the health care facility. On this, the patient gives consent for necessary medical treatment and release of information under certain circumstances. If the patient needs a specialized procedure, such as surgery or a blood transfusion, a separate consent form is needed. Who can sign the consent? The patient, if he is: • Capable of understanding • Legally an adult • Able know the contents of the consent form (if he is deaf, illiterate, or does not speak English an interpreter must be provided to explain the terms of the consent). If the patient does not meet even one of the above terms, another person must be legally designated to sign the consent. This may be a parent, legal guardian, or court conservator.

Defamation

A person can be defamed when false or careless communication is carried out about that person and the person's reputation is harmed. Defamation includes both libel and slander. Libel occurs when the defamation is in printed material and slander is defamation by the spoken word. Kozier explains that the nurse would defame (by slander) another nurse or caregiver by telling the patient that person is incompetent. There is an exception in healthcare if the nurse makes a statement to a supervisor regarding professional care given to patients. To avoid defamation, this communication must be given in good faith with the intent to protect the quality of patient care. For example, if the nurse suspects a fellow caregiver is using illegal drugs or drinking alcohol while on duty, it is the nurse's obligation to report this possibility to an authority in the hospital chain of command.

In summary, what are the 6 rules of thumb for obtaining informed consent?

According to the American Medical Association at www.ama-assn.org: Informed Consent Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention. In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient: • The patient's diagnosis, if known; • The nature and purpose of a proposed treatment or procedure; • The risks and benefits of a proposed treatment or procedure; • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance); • The risks and benefits of the alternative treatment or procedure; and • The risks and benefits of not receiving or undergoing a treatment or procedure. In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

1. Discuss the standards of the California Nurse Practice Act. What is the scope of Registered Nursing practice?

According to the California Nurse Practice Act at www.rn.ca.gov, the scope of Registered Nursing practice is as follows: Business and Professions Code, section 2725: (b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist, as defined by Section 1316.5 of the Health and Safety Code. (3) The performance of skin tests, immunization techniques, and the withdrawal of human blood from veins and arteries. (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures.

Describe the legal responsibilities of student nurses.

According to the California Nursing Practice Act, Section 2729: 2729. Services by student nurses Nursing services may be rendered by a student when these services are incidental to the course of study of one of the following: (a) A student enrolled in a board-approved prelicensure program or school of nursing. (b) A nurse licensed in another state or country taking a board-approved continuing education course or a postlicensure course. Nursing students are responsible for their own actions and liable for their own acts of negligence committed during the course of clinical experiences. When they perform duties that are within the scope of professional nursing, such as administering an injection, they are legally held to the same standard of skill and competence as a registered nurse. Pre-licensure nursing students are not usually considered employees of the agencies in which they receive clinical experience because the nursing education programs have contracts with these agencies. Students in clinical courses must be assigned activities within their capabilities and be given reasonable guidance and supervision. To fulfill responsibilities to patients and to minimize chances for liability, nursing students must meet the following requirements: • Make sure you are prepared to carry out the necessary care for assigned patients. • Ask for additional help or supervision in situations for which you feel inadequately prepared. • Comply with the policies of the agency in which you are working • Comply with the policies and definitions of responsibility supplied by the school of nursing NOTE: Students who may work outside of school hours as nurses' aides must remember that while at work they may legally perform only those tasks that appear in the job description of a nurse's aide. Even though they have received instruction and acquired competence in performing R.N. level tasks, the students cannot legally perform these tasks while employed as an aide.

dependent functions

Administration of medications and therapeutic agents, treatment regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist.

what is a contract?

An offer to provide goods or services and an acceptance of the offer by another person in return for some sort of consideration, usually money. To be legally binding, there must be consent, consideration and competent parties.

So, what is gross negligence? 1442. Gross Negligence

As used in Section 2761 of the code, "gross negligence" includes an extreme departure from the standard of care which, under similar circumstances, would have ordinarily been exercised by a competent registered nurse. Such an extreme departure means the repeated failure to provide nursing care as required or failure to provide care or to exercise ordinary precaution in a single situation which the nurse knew, or should have known, could have jeopardized the client's health or life. (title 16: California Code of Regulations) Nurses are legally protected when they follow certain standards for giving patient care. Nurses have three general duties: to observe, to intervene and to protect. Observe. It is the nurse's responsibility to watch the patient for complications or a change in condition. Some examples of failure to observe are: • When the patient's condition undergoes rapid change, such as after surgery or during labor • After the patient suffers an injury while in the facility • When the patient is known to have self-destructive tendencies Intervene. The nurse must intervene on the patient's behalf, communicate clearly and promptly when problems arise, and use good judgment. The nurse has to prevent injury to the patient. This may mean contacting the physician about a change in the patient's condition or deciding a prescribed treatment is inappropriate for this patient. The nurse is expected to persist in attempts to notify a physician or convince the physician of the seriousness of the patient's condition. Any communication about a patient's condition must be thorough and accurate and given to the correct persons. This communication must be "timely"; for example, it does no good to call the physician hours after the patient's wound started bleeding heavily! Protect. The nurse is expected to prevent the patient from injuring himself or becoming injured by something or someone else. Common examples include falls, use of restraints, burns and equipment malfunction. • Patients can be protected from falls by assessing the patient carefully, using protective measures and giving assistance & supervision when needed. • Restraints can prevent harm or cause harm. If used, restraints must be checked frequently and removed promptly when they are no longer needed. Attempts must be made to keep the patient safe without using restraints. • Burns can be caused by heating pads, bath water, hot water enemas, or heat lamps. Patients with decreased sensitivity to heat or who are sedated or unconscious may not be able to tell if they are being burned. • Equipment injuries can involve failure to monitor the equipment or to correct an equipment problem. Human error is usually the problem: the nurse is rushing, careless or misusing the equipment.

How does the nurse verify that the patient understands the consent?

Ask the patient to state in his own words what he has been told about the procedure. If the nurse feels the patient does not completely understand or is not able to make a decision clearly, the nurse must notify the physician before the procedure is done.

types of contracts

At-will: If a nurse works at a non-unionized hospital or facility, he/she is an at-will employee. This means the employer can terminate an at-will nurse at any time without cause. If a nursing unit is closed, the nurse may be terminated without explanation. If a nurse is found to be incompetent, insubordinate or abuses patients, the nurse may be terminated "with cause". Personal contract: The nurse may be employed for a specific time period with a written contract. Traveler nurses or private duty nurses are employed by personal contracts. Their jobs may be terminated at the end of the contract if it is not renewed. Union contract: Under a union contract, the nurse is protected by the provisions of that negotiated contract. There will be a grievance process if the nurse is suspended or terminated. Civil service contract: Nurses working under the civil service, such as the Veterans' Administration hospitals, have the protection of a grievance process and may appeal any suspension or termination. Health care contracts: Nurses enter into contracts with patients as well as employers. Nurses agree to give competent care, and the patients agree to pay for the services. When patients sign admission forms, they agree to that contract.

Explain the moral principles of autonomy, non-maleficence, beneficence, justice, fidelity and veracity

Autonomy is the right to make one's own decision. The nurse should ask: Am I exploiting this patient, treating him paternalistically (like a parent), or otherwise affecting him without his free and informed consent? Non-maleficence is the duty to do no harm. Ask: Will my actions harm the patient, his caregiver or members of the general public? Beneficence is doing good. Ask: Is this an occasion to do good to others? Remember that we can do good by preventing or removing harms. Justice is being fair. Ask: Am I treating others fairly? Do we have fair procedures? Am I producing just outcomes? Am I respecting morally significant rights and entitlements? Fidelity is being faithful. Ask: Am I being faithful to my institutional and professional role? Am I living up to the trust relationships that I have with others? Veracity is telling the truth. Ask: Am I telling my patient and his family the truth? Do I follow through with what I say I will do?

independent functions

Direct and indirect services that insure safety, comfort, personal hygiene, protection, prevention and restorative measures, delegation/supervision, observation of signs and symptoms of illness, react ion to treatment, general behavior, physical condition, implementation of appropriate reporting or referral, education. These functions do not require a doctor's order.

The first level of moral thinking is that generally found at the elementary school level.

In the first stage of this level, people behave according to socially acceptable norms because they are told to do so by some authority figure (e.g., parent or teacher). This obedience is compelled by the threat or application of punishment. The second stage of this level is characterized by a view that right behavior means acting in one's own best interests.

. Explore the cognitive moral development theory of Lawrence Kohlberg.

In your clinical courses, you will be required to evaluate certain developmental stages for each of your patients: physical, intellectual, psychosocial and moral. The first three stages will be studied in greater depth at a later date. The Santa Ana College R.N. program uses Lawrence Kohlberg's moral development theory for moral developmental stages. Moral development usually takes place in childhood. It is important to understand these stages of moral development in order to evaluate where your patient fits. It is important to know and understand the stage your patient is in so you can correctly communicate with your patient in his moral choices. Lawrence Kohlberg was, for many years, a professor at Harvard University. He became famous for his work there beginning in the early 1970s. He started as a developmental psychologist and then moved to the field of moral education. He was particularly well-known for his theory of moral development which he popularized through research studies conducted at Harvard's Center for Moral Education. His theory of moral development was dependent on the thinking of the Swiss psychologist Jean Piaget and the American philosopher John Dewey. He was also inspired by James Mark Baldwin. These men had emphasized that human beings develop philosophically and psychologically in a progressive fashion. Kohlberg believed...and was able to demonstrate through studies...that people progressed in their moral reasoning (i.e., in their bases for ethical behavior) through a series of stages. He believed that there were six identifiable stages which could be more generally classified into three levels.

Kohlberg's classifications can be outlined in the following manner:

LEVEL STAGE SOCIAL ORIENTATION Preconventional 1 Obedience and Punishment 2 Individualism, Instrumentalism, and Exchange Conventional 3 "Good boy/girl" 4 "Law and Order" Post-conventional 5 Social Contract 6 Principled Conscience

Compare and contrast morality and bioethics.

Morality: Nurses, patients, families and other health team members all have their personal standards of right and wrong. Most people have what is called a conscience that tells them how they should respond in different situations. Many people use the terms "morality" and "ethics" interchangeably. Nursing is concerned with bioethics as we apply our moral (or ethical) standards to health care situations. Some situations may demand bioethical decisions applied to such issues as abortion, euthanasia, withdrawal of life support, etc. It is important for the nurse to consider these issues before assisting patient and their families in their decision-making process.

Discuss legal protections in nursing practice.

Nurses have three separate, interdependent legal roles, each with rights and associated responsibilities. 1. Provider of service. The nurse is expected to provide safe and competent care so that harm (physical, psychological, or material) to the recipient of the service is prevented. Implicit in this role are several legal concepts: liability, standard of care, and contractual obligations. Liability is the quality or state of begin legally responsible to account for your obligations and actions and to make financial restitution for wrongful acts (for instance, the nurse has an obligation to practice so that no harm comes to the patient). When a nurse is asked to carry out an activity that the nurse believes will be harmful to the patient, the nurse's responsibility is to refuse the carry out the order and report this to the nurse in charge. If the nurse follows this procedure, the nurse is protected by the law. Standard of care. The standard of care the nurse must follow is legally defined by the California Nurse Practice Act and is the rule of what a reasonable and prudent nurse with similar preparation experience would do in similar circumstances.

Interdependent-standardized procedures:

Some dependent functions can be written ahead of time to allow nurses to act in certain (often emergency) situations. These practices overlap the practice of medicine. See Business and Professions Code, #2725: (c) "Standardized procedures," as used in this section, means either of the following: (1) Policies and protocols developed by a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code through collaboration among administrators and health professionals including physicians and nurses. (2) Policies and protocols developed through collaboration among administrators and health professionals, including physicians and nurses, by an organized health care system which is not a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code.

Who can witness a consent?

Some who is not related to the patient and not involved in the procedure may witness the patient's signature. The nurse can witness (and often does) unless he or she is on the team caring for the patient during the procedure.

Who has the primary responsibility to obtain consent for a procedure?

The law obligates whoever is going to perform a procedure to discuss it with the patient. This person is generally a physician, however, if a nurse practitioner or physician's assistant will perform the procedure, that person must talk with the patient and obtain consent.

The second level

of moral thinking is that generally found in society, hence the name "conventional." The first stage of this level (stage 3) is characterized by an attitude which seeks to do what will gain the approval of others. The second stage is one oriented to abiding by the law and responding to the obligations of duty.

What is the nurse's role in obtaining informed consent?

The nurse's role is to be an advocate for the patient: protect his rights, preserve his dignity, identify his fears, and determine his level of understanding and approval for the procedure.

4. Explain areas of potential liability in nursing.

There are several areas of potential liability in nursing practice, either intentional or unintentional. Torts are wrongs committed against a person or his property: either something was done wrong or something that should have been done was omitted. These can be either intentional or unintentional.

False Imprisonment

This is the restraint of a person not in legal custody without his permission. Patients may wish to leave the hospital without the physician's permission. They are asked to sign an AMA (Against Medical Advice) form to acknowledge they are leaving without permission and then they may leave. Before doing this, the nurse needs to consult with the supervisor and physician to determine if the patient would be in danger by leaving. Another situation is physical restraint of a patient who is confused and combative and wants to get out of bed and would be injured by doing so. Each care-giving facility has procedures in place to deal with these situations - the nurse follows those procedures exactly to avoid falsely imprisoning their patients.

Unintentional Torts

Unintentional torts in health care are classified as either negligence or malpractice. In California, negligence is misconduct that is below the standard expected of an ordinary, reasonable and careful person. This misconduct places another person at risk for harm. Both medical and professional healthcare practitioners can be liable to negligent acts. Malpractice is professional negligence that causes harm. This negligent act occurred while the personal was performing as a professional. A registered nurse would qualify while performing in the role of the R.N. This does not necessarily mean the nurse is on duty and being paid to work. It could be a volunteer situation in which the person is acting as an R.N., for instance as a camp nurse. While acting as an R.N., the nurse was negligent and that act caused harm to the patient.

Intentional torts

are actions by the nurse that may not cause harm to the patient but do cause liability for the nurse. Read about these 5 examples in Kozier: • Assault • Battery • False imprisonment • Invasion of privacy • Defamation

Invasion of privacy

how can a nurse invade someone's privacy? In July, 2013, the Los Angeles Times reported that six employees of Cedars-Sinai Medical Center were fired for breaching a patient's privacy: Five workers and a student research assistant at Cedars-Sinai Medical Center have been fired over privacy breaches involving patient medical records. Cedars-Sinai officials said in a statement that 14 patient records were "inappropriately accessed" between June 18 and June 24. Six people were fired over the breach: four were employees of community physicians who have medical staff privileges at the hospital, one was a medical assistant employed by Cedars-Sinai, and one was an unpaid student research assistant. Reality television star Kim Kardashian gave birth to her daughter with rapper Kanye West at the hospital on June 15. A hospital spokeswoman declined to identify the patients whose records were accessed but said that all patients involved had been notified of the breach. Five of the workers accessed a single patient record; the other one looked at 14. The people involved will be permanently denied access to Cedars-Sinai records even if they go on to work for other health providers, the hospital said. Community physicians have access to the hospital's electronic record system but are supposed to log in only for purposes related to the care of their own patients. Cedars-Sinai officials said three community physicians — Dr. Sam Bakshian, Dr. Abraham Ishaaya, and Dr. Shamim Shakibai — had given their user names and passwords to employees in violation of hospital policy, and the employees used the log-ins to access confidential patient records. In the other case, a doctor's employee had been granted a separate user ID and password at the physician's request, to assist in billing.... The federal Health Insurance Portability and Accountability Act sets limits on what health information can be disclosed without a patient's permission. Violations can lead to fines of up to $50,000 per violation and, in some cases, to criminal charges.... Breaches of patient records — particularly celebrity records — have been a recurring problem for Los Angeles hospitals. UCLA Health System found itself at the center of a scandal in 2008 involving workers who snooped into the medical records of Britney Spears, Farah Fawcett and Maria Shriver, among others. One former employee was convicted of selling celebrity medical information to the National Enquirer. UCLA agreed to pay $865,500 as part of a settlement with federal regulators. Employees at Kaiser Permanente's Bellflower hospital pried into the records of "Octomom" Nadya Suleman, leading state regulators to levy a $250,000 fine. http://articles.latimes.com/2013/jul/12/local/la-me-hospital-security-breach-20130713 The HIPAA act described above requires that the nurse protect the patient's privacy. This is discussed in greater depth in Kozier, p.66

assault

is an attempt or threat to touch another person without his permission. This can happen in healthcare if the nurse threatens a patient. What if the patient does not want the medicine or procedure the nurse is about to give or do? What if that medicine or procedure is good for the patient, but he does not want it? Think about it and we'll discuss this issue in class.

Battery

occurs when a person or his possession is touched without his permission, or if he is embarrassed or injured by the touching. How can this happen in healthcare? Many times, battery is preceded by assault - the nurse threatens something and then follows through with the threat. What is the nurse threatened a patient with a sedative injection if he "doesn't behave". The patient continues "not behaving" and so the nurse gives the unwanted injection. This is illegal even if the medicine was ordered and was good for the patient. Procedures require consent, either written or verbal, before they can be performed. The exception is in life-threatening emergencies. It is implied that the patient would want life-saving treatment. Another possible scenario is if the patient is deemed incompetent to make decisions. This is usually decided in court hearings, but consultation with a supervisor may make an exception in certain situations.

The third level

of moral thinking is one that Kohlberg felt is not reached by the majority of adults. Its first stage (stage 5) is an understanding of social mutuality and a genuine interest in the welfare of others. The last stage (stage 6) is based on respect for universal principle and the demands of individual conscience. While Kohlberg always believed in the existence of Stage 6 and had some nominees for it, he could never get enough subjects to define it, much less observe their longitudinal movement to it. Kohlberg believed that individuals could only progress through these stages one stage at a time. That is, they could not "jump" stages. They could not, for example, move from an orientation of selfishness to the law and order stage without passing through the good boy/girl stage. They could only come to a comprehension of a moral rationale one stage above their own. Thus, according to Kohlberg, it was important to present them with moral dilemmas for discussion which would help them to see the reasonableness of a "higher stage" morality and encourage their development in that direction. Read more about Kohlberg's theory in Kozier, page 364 and in Table 20-6 on page 366.

In what situations is an informed consent not required?

• An emergency, such as surgery to save the patient's life. Two physicians must sign the consent. The law assumes that all patients would want to live. • If the patient chooses not to hear the explanation and signs a waiver to that effect. For example, if a patient states, "I really don't want to know the details; they just upset me." • If the procedure is done because of a court order, such as a blood alcohol level.