Exam 3 - Comps 6, 7, 9 leadership

Utilitarianism

- What results in the greatest good for the most people - Value of the act is determined by its usefulness, emphasis on outcome or consequences

"Whistleblowing"

- When a current or former employee warns the public about a serious wrongdoing within an organization. - Federal and state protection (pending state law) - Does not cover private sector - ANA's Things to Know About Whistleblowing - *Internal whistleblowing* occurs within an organization, reporting up the chain of command. - *External whistleblowing* involves reporting outside the organization, such as to the media or an elected official

False imprisonment can become the basis of a lawsuit in healthcare settings. Which of the following is a typical example of false imprisonment of a client by a Registered Nurse?

Independently applying a vest restraint to a client to keep the client from ambulating without assistance.

Moral distress

Individual knows the right thing to do but organizational constraints make it difficult to take the right action (2 ethical principles compete) - Can cause stress, depression, and lead to turnover

Moral outrage

Individual witnesses immoral act of another but feels powerless to stop it

Battery

offensive touching without consent

The new graduate nurse is applying for a position with a healthcare organization. Which of the following statements by the nurse recruiter indicates that the organization supports an ethical workplace?

"Our policies and procedures reflect current evidence-based research and national standards."

ANA Provisions (9)

1) nurse practices with compassion and respect of everyone 2) The nurse's primary commitment is to the patient 3) The nurse promotes, advocates for, and protects the rights, health, and safety of the patient 4) The nurse has authority, accountability, and responsibility for nursing practice 5) The nurse owes the same duties to self as to others 6) The nurse establishes, maintains, and improves the ethical environment of the work setting and conditions of employment 7) The nurse, in all roles and settings, advances the profession through research and scholarly inquiry 8) The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and *reduce health disparities* 9) The profession of nursing must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice

The registered nurse must understand the meaning of malpractice. Which of the following is the best description of malpractice?

A form of negligence in which professional misconduct, lack of skill or non-adherence to accepted standard of care causes injury to a client.

Power of Attorney (POA)

A legal document executed by an individual *granting another person the right to make health care decisions for them* if temporarily or indefinitely incapacitated.

Which of the following statements best defines shared governance:

A organizational model whose foundation is the professional workplace.

The registered nurse utilizes the ANA Code of Ethics. Which of the following best describes the purpose of this document?

A statement of the obligations and duties of all individuals who enter the nursing profession

Deontological

Actions are based on moral rules and unchanging principles such as "do unto others as you would have them do unto you" - Motives determine goodness

Moral Indifference

Individual questions why morality in practice is even necessary

Rights-based Reasoning

Belief that some things are an individual's entitlement or right

Intuitionist Framework

Decision-maker reviews case-by-case based on intuition, questionable as it may be subjective and biased

The ANA reviews regulations of particular interest to the nursing community, analyzing them and identifying concerns. Which of the following agencies does the ANA monitor as part of their advocacy for nurses in political and policy areas? *Select All That Apply*

Department of Justice Department of Labor Department of Veterans Affairs

Ethical decision-making is an integral part of professional nursing practice. Which of the following is is the basis for ethical decision-making?

Determining right or wrong based on a body of knowledge

The nurse is working with a client who has a terminal diagnosis and who is facing difficult decisions around end-of-life care? How can the nurse best advocate for this client.

Ensure the client receives all the necessary information to make an informed choice

When the registered nurse lobbies for a universal health care bill that covers all individuals, the registered nurse is demonstrating what essential value of nursing?

Equality

A community health registered nurse commits to a client to accompany them on a doctor's clinic visit which the client is very worried about. A scheduling conflict develops, but the RN decides to attend the clinical visit. Which ethical principle is demonstrated by this nurse's decision?

Fidelity

The registered nurse takes action to decrease risk of liability. Which of the following acts will best result in reduced risk?

Follows evidence-based standards of care

Defamation

Giving false information injuring a person's reputation ◦ *Libel* - when defamation is written, printed, broadcast (risk w/ social media) ◦ *Slander* - when it is spoken

The off-duty registered nurse stops at a road side motor vehicle accident to render first aid. Which of the following laws protects the registered nurse from malpractice in this situation?

Good Samaritan Immunity Act

Which statement concerning the queen bee syndrome is true?

It prevents sharing of power The queen bee syndrome is when a person struggles to power and once successful/in power they refuse to assist others to gain power or success. As nurses we need to empower and mentor future nurse leaders, rather than keep power to self and continue to be controlling or ruling as one leader.

The registered nurse administered a medication at the wrong time which caused harm to the patient. For which of the following can the RN be held liable?

Malpractice

NCSBN

National Council of SBON's (state board of nursing) - Central clearinghouse across states - Ensures state actions against a nurse's license are recorded/enforced in all states

The ANA Code of Ethics and many state nurse practice acts require the RN to serve as the patient advocate. When the RN fails to advocate for the patient by carrying out a potentially questionable order, for which of the following can the nurse be held liable?

Negligence or malpractice

Joint Liability

Nurse, physician & employer all held liable - Reflects higher level of accountability, Share the blame - Employer may seek to recover charges from negligent employee

Which statement is true concerning political action of nurses?

Nurses have not yet recognized the full potential of political activity

In 2011, The Institute of Medicine and the Robert Wood Johnson Foundation published the landmark initiative known as The Future of Nursing: Leading Change, Advancing Health. Which of the following are aspects of the key message from this important study? *Select all that apply*

Nurses should practice to the full extent of their education and training Nurses should achieve higher levels of education and training through seamless academic progression. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the US.

Which of the following are common areas requiring nurse-client advocacy? *Select All That Apply*

Obtaining client informed consents Preventing medication errors Facilitating access to health-care services Promoting respect for client dignity and cultural values

What law is the registered nurse upholding when the nurse explains information regarding living wills to a client who has been just admitted to an acute care facility?

Patient Self-Determination Act

Informed Consent

Person giving consent *must fully comprehend:* - Procedure to be performed - Risks & benefits of each option (incl. doing nothing) - Expected or desired outcomes - Possible Complications or side effects - Alternative treatments available *Consent may be given by:* - A competent adult - Legal guardian or durable power of attorney - Emancipated or married minor - Parent of a minor child - Court order *Nurse acts as the patient advocate*

The State Board of Nursing has the responsibility to discipline nurses when appropriate. For which of the following actions can the registered nurse be subject to disciplinary action by the State Board?

Practices nursing without a valid nursing license

HIPPA

Privacy - Protects person's reputation and prohibits exposure of patient name, picture, other info

The nurse is reviewing the provisions of legislation that relates to nursing practice in the jurisdiction where the nurse provides care. The nurse should identify what primary purpose of this legislation?

Protecting clients' rights and safety

Incident Reports

Report of an unusual or unexpected occurrence or incident - Confidential communication - do NOT discuss with patient - Cannot be subpoenaed as evidence in most states - *NEVER note existence of incident report in medical record* - RN legally bound to report critical incidents within 24 hours (by Joint Commission) *NEVER photocopy an incident report, no subjective statements*

The RN is concerned with the ethical nature of decision-making. Which of the following actions is both legal and unethical?

Reporting a gunshot victim to law enforcement against the victim's wishes

The registered nurse is caring for a client post-op day 2 from a carotid endarterectomy. The client begins to experience right sided facial drooping, slurred speech and confusion. The nurse documents the client's condition but does not contact the health care provider. The nurse in this situation may be liable for what malpractice error?

Reporting change of condition

A group of nurses have formed an action group that has the goal of increasing professional power of the nursing profession. What strategy should the group adopt?

Seek formal positions where members can influence public policy

After working toward change internally and being ignored, a nurse is preparing documentation to report an employer for allowing the re-use of surgical equipment without proper sterilization. Which of the following best relates the ANA recommendations on this topic?

The nurse should collect sufficient data of wrongdoing, document all interactions and keep copies.

The registered nurse left the client's bed in the elevated position following cares since another care would be needed shortly and the nurse felt rushed. The client subsequently fell and was injured. Which of the following best describes the legal reasoning relating to the nurse's liability?

The nurse was not following the reasonable standard of care and will likely be found liable

In studying ethical decision-making, a registered nurse may participate in a values clarification exercise to help identify their own unique value systems. The RN understands that which of the following is the appropriate application of their own values?

Values are individual and should not be imposed on patients.

When the registered nurse reports a case of HIV to the public health department as required, the registered nurse is functioning under which of the following ethical principles?

Veracity

Nurse Licensure Compact

WI - N9 - License in one NLC state allows practice in others

Assault

threat to touch in offensive way

Nursing Practice Act

◦ Board of Nursing may seek to revoke licensure or institute discipline ◦ Burden of proof varies state to state - Precedent is often used as a guide: ◦ Previous case must be in the same jurisdiction - Landmark decisions may depart from precedent: societal change, technological advancement

Ethical vs Nonethical

*Ethical:* - When an action freely performed (or not performed) has potential to harm or benefit others. - May result in harm *Nonethical:* - "Practical dilemmas" - "Decisional Conflicts" - Claims of self-interest or choices based on personal values - Action (or lack of action) does not harm others or cause considerably less benefit to another

Respect

*Most basic and universal. All other principles stem from this* - Transcends cultural differences, gender issues, racial concerns

Malpractice/Professional Liability Insurance

*Provides an assurance and pays for an attorney to defend the nurse in a malpractice lawsuit* - Many Nurses carry their own malpractice insurance - Needed in expanded and advanced practice roles - Can purchase through ANA/WNA - *Employer policies have limitations:* may not cover if terminated, may be inadequate

WI NPA - N7

*Rules of Conduct* - Specifies grounds for: limiting, suspending, revoking, or denying renewal of a license... as well as reprimanding a licensee

WI NPA - N6

*Standards of Practice - RN & LPN* - Utilizing the Nursing Process ◦ Assessment & Diagnosis, Planning, Intervention and Evaluation - Performance of delegated acts - Supervision and Direction of delegated acts

Mandatory Reporting

- *Child Abuse and Neglect:* any reasonable cause to *suspect* that a child has been that abused or neglected - *Elder Abuse:* *Reasonable cause* to believe that an elder or adult is at imminent risk of serious bodily harm, death, sexual assault, or significant property loss and is unable to make an informed judgment about whether to report the risk

Laws to Know...

- *Nurse Practice Acts*: governed by state board of nursing... Education, disciplinary measures, nursing practice - *Equal Opportunity Act 1972*: Defines & prohibits sexual harassment in the workplace, Prohibits discrimination in hiring - *EMTALA 1986*: All persons must receive same medical exam & be stabilized, regardless of financial status or insurance, before discharge or transfer ◦ Applies to ER, urgent care, and inter-agency transfers *Nursing practice is affected by rapidly changing laws and legislation* *Organizational laws may differ from state or federal law*

Autonomy

- A person's right to personal freedom, *self determination* - *The right to choose or refuse* - Requires that clients have adequate information about treatment options - *Patient Self Determination Act of 1990:* Competent people could make end-of-life choices known

Charge Nurse Role

- Assignment, Delegation, Supervision - Duty to Orient, Educate, Evaluate - Issues if: failure to warn (employee under the influence), staffing issues - Keep staffing ratios in mind, overtime has been shown to increase risk of med errors, infection, needle sticks - Floating can increase potential liability if short-staffed and incompetent

Nurses Role in Ethical Decision Making

- Be an advocate and facilitator for the client facing an ethical decision - Requires an orderly, systematic and objective method, model or framework - Always a process (ADPIE, MORAL)... allow sufficient time Review the facts (outcomes, options, consequences, goals, desires) Identify the ethical issue of the situation

Ethical Dilemma

- Being forced to choose between two or more undesirable alternatives - Three Characteristics: 1) Cannot be solved using only empirical data 2) So perplexing that deciding what facts & data need to be used in making the decision is difficult 3) Results of the problem affect more than the immediate situation

Ethics

- Branch of philosophy concerned with determining what is right or wrong on the basis of a body of knowledge *rather than on opinion* - System of moral conduct and principles that guide a person's actions in regard to right and wrong and in regard to oneself and society at large - Enforced via ethics committees and professional codes

Building Political Skills

- Build a relationship with a legislator. - Be an active member of a professional nursing organization. - Run for office in your organizations, your community, your legislature. - Develop expertise in shaping policy. - Join a Professional Nursing Organization

State Nursing Practice Act

- Defines the scope and standards of practice - NPA contains the following information: ◦ Definition of the term registered nurse ◦ Description of professional nursing functions ◦ Standards of competent performance ◦ Behaviors that represent misconduct or prohibit practices ◦ Grounds for disciplinary action ◦ Fines and penalties the licensing board may levy when the NPA is violated

Malpractice

- Failure of person with professional education & skills to act in a reasonable and prudent manner - Common Causes is a Failure to: follow standard of care, communicate appropriately, assess & monitor patient, act as patient advocate

Professional Code of Ethics

- Formal statements of values & beliefs of a profession - Purposes: Inform public of minimum standards of conduct of members and professionals responsibilities Outlines ethical considerations of the profession Guidelines for professional practice to members Guide for self-regulation within the discipline

How a nurse can act as an advocate?

- Helping others make informed decisions - Acting as intermediaries in the environment - Directly intervening on behalf of others - Advocating for social justice

Veracity

- Honesty - Obligation to tell the truth, the complete truth

Shared Governance

- Introduced in the 1980s - Nurses at every level play a role in the decisions that affect nursing activity throughout the system. - Nurse-managers move out of traditional, industrial model roles into collegial models, becoming moderators of the service process. - Usually defined by a structure of rules or bylaws - *A democratic, egalitarian concept* - A dynamic process that empowers nurses - A process of shared decision-making and accountability - A hallmark of Magnet organizations! (Nurses have a voice)

Fidelity

- Loyalty - Keeping promises or commitments

Standard of Care

- Minimum requirements for acceptable practice or conduct - Based on: State Nurse Practice Act, Institutional policies and procedures, Job description, Standards by professional organizations (ANA, Joint Commission), Standing orders and protocols

Advocacy

- Nurses must advocate for themselves, clients, subordinates, and their profession. - Advocates must inform others of their rights and make sure they have enough information to make informed decisions.

Nonmaleficence

- Obligation to *do no harm* - Prohibits deliberate harm and demands weighing risks with benefits of client treatment

Justice

- Obligation to *treat all persons equally and fairly* - Individuals are given what they are entitled to, deserve, or can legitimately claim - Principle has to do with the fair allocation of resources

Values in Nursing

- Personal beliefs about worth that acts as a standard to guide behavior - Each person's framework on which actions are based - Nurses must acknowledge their own values by considering how they would act in a given situation or what's important... *but never impose personal values on client decisions*

Action Plan for Increasing the Power of the Nursing Profession

- Place more nurses in positions to influence public policy - Increase nurses level of understanding regarding policy - Build confidence within the nursing field - Promote greater research to strengthen Evidence Based Research - Support Nursing Leaders - Mentor future nurse leaders

What can be done to avoid malpractice claim?

- Practice within scope of the NPA - Know & follow agency policies & procedures - Use EBP and follow established standards - Put patient rights and welfare FIRST - Base nursing decisions on relevant law, legal doctrines, as well as bio-psycho-social sciences - Practice within area of individual competence -Upgrade skills through continuing education and specialty certification - Purchase liability insurance!

Grounds for Disciplinary Action

- Practicing without a valid license - Failure to use appropriate nursing judgment - Falsification of records - Failure to complete nursing documentation - Incorrect nursing documentation - Failure to practice in accordance with nursing standards - Inappropriate behavior/occurrence at work - Misappropriation of personal items

Ethics Committees

- Provide structure and guidelines for potential problems - Function as patient advocate - Composed of nurses, physicians, clergy, social workers, nutritionist, pharmacist, administrator, legal experts... Patient and family

Paternalism

- Provider acts in the clients best interest - Only justified to prevent harm to another since it limits freedom of choice of the individual - Principle becomes undesirable when an entire decision is taken from a client or important information withheld

Confidentiality

- Respecting privileged information - Overridden only when law requires reporting of certain information: Child abuse Elder abuse Drug abuse in employees

Beneficence

- The *desire to do good* - Act in the best interests of another person -

Nursing "Power"

- The authority and ability to get things accomplished - The capacity or potential to get others to do something one wants them to do that they would not ordinarily do otherwise - The potential of an individual or group to influence the behavior of others - Gives one the potential to change the attitudes and behaviors of individual people and groups

IOM Report: "The Future of Nursing"

- The changing landscape of patient needs requires nurse to be educated differently in the 21st century than in the past - Focus on: Life long learning, Bachelor's of Science in Nursing, Graduate and PhD programs, Nurse residency programs

4 Fundamental Responsibilities of Nursing Practice

- To promote health - To prevent illness - To restore health - To alleviate suffering

Essential Values of Nursing

1) *Altruism:* concern for the well-being of others 2) *Autonomy:* right to self-determination 3) *Dignity:* maintain an individual's self-worth 4) *Integrity:* acting within an accepted code of practices, ethics... 5) *Social Justice:* upholding what is fair, advocate for socially just policies

5 Elements that must be present to hold a professional liable:

1) Standard of Care = Duty owed to the patient 2) Breech of duty 3) Foreseeability of harm: knowledge that harm could be possibility, ignorance is not an excuse 4) Causation: failure to meet standard, correlation is proveable 5) Actual Injury: physical, emotional, financial

The registered nurse caring for a client diagnosed with end stage metastatic cancer whose pain is uncontrolled. It is time for the next pain medication. The provider has written a new order for morphine sulfate IV push 1-4 mg as needed every 1-2 hours "titrate to comfort" to replace the prior order of morphine sulfate 1 mg IV push every hour. Which of the following is ethically the best action for the nurse to take?

Administer 2mg morphine IVP, assess client restlessness, respirations and comfort level.

The nurse manager has an employee with a self-reported chemical dependency. According to the ANA Code of Ethics, what is the best action the nurse manager can take?

Assist the nurse in obtaining appropriate assistance, treatment and fair institutional processes.

Universalism

Ethical principles are universal and constant, don't vary by circumstance or cultural differences Universal truths (ie: "murder is always wrong") - Opposite of relativism (what seems reasonable based on culture)

Living Will

Written instructions regarding desired end-of-life care May address: dialysis, respirators, resuscitation, tube feeding, organ or tissue donation

False Imprisonment

◦ Improper use of physical or chemical restraints ◦ Must have MD order: Immediate contact w/MD

Leaving AMA

◦ Patients have the right, ask them to sign the form ◦ Promptly notify provider ◦ Is there *risk for immediate physical harm?*