Evidence-Based Practice and Legal Aspects in Nursing Care, Study Guides, Projects, Research of Nursing

Download Evidence-Based Practice and Legal Aspects in Nursing Care and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Introduction to Evidence Base Practice Study Guide Testing traditional approaches to client care for continued relevance and effectiveness is nursing research. This testing provides clinical guidance. Research conducted by nurses includes various types of studies and tests to derive clinical interventions for assisting those who require nursing care. Journal clubs review current research to bring new evidence into everyday practice. Ideally, clinician preferences match best practices/clinical research recommendations, but some clinicians may not practice according to the evidence, which may put a client at risk. Evidence can be used as a basis for which of the following aspects of nursing practice? Select all that apply. Policies and procedures, nursing assessment, standing order sets, and care decisions for clients are all examples of using evidence. Evidence provides the basis for effective, efficient client care practices. Nurses and other healthcare professionals can incorporate evidence into virtually every phase of the healthcare process. The type of facility a client is transferred to after inpatient care is determined by the type of care needed. The creation of the National Center for Research for Nursing in 1986 was a seminal step in recognizing the importance of nursing research. projects do not place clients at greater risk. Clinical situations and outcomes are reviewed, and the organization looks at operations, staffing, and other factors that could improve outcomes. A staff nurse with a bachelor’s degree is interested in helping with research. They will evaluate research for application to practice. Evaluating research and providing feedback to the author is an advanced research skill. When an individual nurse applies the nursing process for problem-solving, it differs from research because it takes place at the individual client level. Nurses use the nursing process to understand clients, their specific needs, and to provide care. By evaluating the client's response to care, the nurse can adjust the plan of care. Client care does not require replication before it is helpful to the client. The reported data that may influence students to not work in the ED includes spending little time with clients, having no coverage for breaks, and work interfering with sleep. Most often, these are reasons nurses leave positions. All nurses communicate with multiple colleagues, including healthcare providers, so this is not unique to the nurses working in the ED. A staffing option that pays for 40 hours of work when 36 hours are actually worked has been used during nursing shortages to recruit, rather than lose nurses. According to the article excerpt presented, nurses working in the ED are at risk for frequent turnover, feelings of burnout, post- traumatic stress, increased sick calls, and elevated blood pressure. The emergency department (ED) nurses should increase their ability to explore their personal beliefs, reduce stress, and find ways to relieve stress in their lives. Nursing research often provides solutions based upon the findings of participant interviews and data. Nurses should take their personal beliefs and needs into consideration, there should be a work-life balance, and they should explore coping methods. Relieving stress at work and during personal time can support that healthy balance. Work being the top priority is not always recommended and disconnecting from clients is not possible during a shift. The most credible research studies are peer reviewed and the information should guide clinical revisions or new practices. Nurses should compare evidence to policies and procedures to decide if practice changes are needed. Joining a professional organization will provide the latest information on research leading to recommended practice changes. Attending online education and in-service training may assist nurses in understanding how evidence connects to their daily practice. Invite librarians to the unit for in-service, and introduce staff to the resources in the organization or online. The evidence-based practice (EBP) process has five basic steps: 1. Formulating the clinical question 2. Searching efficiently for the best available evidence 3. Critically analyzing evidence for its validity and usefulness 4. Integrating the appraisal with clinical expertise and clients' preferences 5. Evaluating one's performance or outcomes of actions Research may be incorporated into practice during assessment (collecting evidence), diagnosis, and evaluation. Using personal experience is not considered best practice as it may be what has worked in the past using trial and error rather than incorporating the best evidence. Evidence-based practice should be used by all members of the healthcare team, not just physicians. The status quo should constantly be challenged to ensure nurses are using the latest and best practices. Nurses should be involved in quality meetings and encouraged to ask questions about policies and procedures. Organizations should have journal clubs and shared governance groups to support the use of research and how it is conducted. A “vulnerable participant” is any individual who cannot fully consent to participate in a study. A limited ability to make decisions means the client cannot fully agree. Education level and a personal relationship with the researcher do not limit the ability to fully consent to study participation. Autonomy is the freedom to choose what will happen to one's person. Incomplete disclosure without informed consent violates this ethical principle. Beneficence is the oath to take positive actions to help clients. An example would be the nurse who puts aside their self- interests to ensure the client's best interests remain most vital. Fidelity is about keeping promises. If you assess that a client is in pain and then discuss ways to manage the pain, fidelity means that you will provide the necessary intervention and continue to monitor the client's pain. Justice is the obligation to treat each client equally or fairly. For example, should organ transplants be available to all clients equally despite the ability to pay? A research study that poses minimal risk to subjects requires which type of Institutional Review Board (IRB) review? An IRB must review all research studies involving human subjects. There are three categories of research review: • An exempt review is limited to research studies that pose no risk for the subjects. • An expedited review is used when a study poses minimal risk for the subjects. • A full review is necessary when research poses more than minimal risk to the subjects. A mandatory review and a fortified review do not exist. The Nuremberg Code: Voluntary consent is required. Any experimentation must be for the greater good of society. If death or disability is likely, experimentation should not occur. The risks of experimentation should never exceed the benefits. Only qualified professionals should conduct experiments and should oversee all stages of the process. The Declaration of Helsinki The Declaration of Helsinki, developed in 1964 as an extension of The Nur emberg Code, was adopted by the World Medical Association and has bee n revised several times, most recently in 2013 (Resnik, 2020). The goal of t he declaration was to distinguish between therapeutic and non- therapeutic research. Allegedly, Willowbrook researchers purposely exposed subjects to hepatitis. After observation, during which infected children were untreated, a vaccine was tested on the subjects. The research community continues to debate the value of this study as it resulted in the hepatitis vaccine currently in use today; however, the researchers purposely harmed a vulnerable student population and parental consent was questionable. The Tuskegee Study Between 1932 and 1972, the Public Health Service conducted a study inve stigating the effects of untreated syphilis on African American men in Tusk egee, Alabama. However, the researchers did not tell the subjects that the y were involved in an experiment. In addition, researchers withheld treat ment from subjects who tested positive for the disease, even though an e ffective antibiotic (penicillin) was available. The study ended in 1972 when a reporter alerted the public and Congress to the ethical dilemmas with th e study. Eventually, the participants and their families filed a lawsuit, whic h the U.S. government settled. As a result of wide-scale public outrage, the National Research Act in 1974 created the National Commission for the Protection of Human Subjects of Biomedical and Behavior Research in the United States. This commission drafted The Belmont Report, which became a foundational document for ethical practices involving human subjects in the United States (Mandal et al., 2011). The Belmont Report In 1978, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research produced The Belmont Report (USDH HS, 2016). The report's primary purpose was to identify basic ethical principles that s hould underlie the conduct of research involving human subjects. The three principles in the report form the cornerstones of human subject research: (1) beneficence, (2) justice, and (3) respect for persons. Beneficence dictates the researcher’s obligation not to harm the research participa nts but also to maximize the possible benefits. Subjects must be made aware of pot ential risks of study participation (Miracle, 2016). One measure defined in The Belm ont Report to protect subjects from harm is the Institutional Review Board (IRB). Th e primary purpose of the IRB is to review research proposals, protect subjects from injury, and ensure risk mitigation measures are in place (Miracle, 2016). Justice demands equal treatment and fairness for all research subjects. All clients re quire proper care and treatment even if they decline to participate in a research stu dy (Miracle, 2016). No subject can receive less than an acceptable standard of care. Finally, all subjects have the right to know the outcome of the study (Miracle, 2016). Respect for persons is based on two ethical concepts: autonomy and prot ection of vulnerable populations (Miracle, 2016). • Autonomy allows people to make their own decisions and choices. R esearch subjects must consent to voluntary participation. Informed c onsent consists of providing information, ensuring comprehension o f that information, and the act of voluntary participation without coe rcion. • Vulnerable populations with diminished autonomy require increase d protection and special consideration before experimentation. Spec ific vulnerable groups include children, prisoners, pregnant women, fetuses, mentally disabled persons, and economically and education ally disadvantaged persons (Gordon, 2020). References Gordon, B. G. (2020). Vulnerability in research: Basic ethical concepts and gene ral approach to review. Ochsner Journal, 20(1), 34-38. https://doi.org/10.31 486/toj.19.0079 Miracle, V. A. (2016). The Belmont Report: The triple crown of research ethics. Dimensions of Critical Care Nursing, 35(4), 223-228. https://doi.org/10.1097/ DCC.0000000000000186 U.S. Department of Health & Human Services. (2016, March 15). The Belmont R eport: Ethical principles and guidelines for the protection of human subjects in research. https://www.hhs.gov/ohrp/regulations-and-policy/belmont- report/index.html A researcher plans to study the effects of a new medication on hypertension. However, only Caucasian males from the northeast will be recruited to participate in the study. Thus, researchers are violating which ethical principle? Justice demands equal treatment and fairness for all research subjects. Clients should not be excluded without good reason. By only including Under the Food and Drug Administration’s (FDA) authority, the Institutional Review Board (IRB) is a group that is formally designated to review and monitor research involving human subjects. To protect the rights and well-being of human research subjects, the IRB has the authority to approve, require modifications, or disapprove research (U.S. Food & Drug Administration, 1998). Every institution is not required to have its own IRB. However, FDA regulations permit an institution without an IRB to arrange for an “outside” IRB to be responsible for the initial and ongoing approval of research studies conducted at a non-IRB institution (U.S. Food & Drug Administration, 1998). The primary purpose of the IRB is to protect human research subjects. An IRB must review all research studies involving human subjects. There are three categories of research review. Review the interactive to the right to learn more. Three Categories of Research Review Transcript Reference U.S. Food & Drug Administration. (1998, January). Institutional review boards frequently asked questions. https://www.fda.gov/regulatory- information/search-fda- guidance-documents/institutional-review-boards- frequently- asked-questions To qualify for review at the exempt level, the research must pose no risk to subjects. Examples include collecting information from a medical database, interviewing nurses about perceptions of outcomes, and observing adults in social situations. To qualify for review via expedited procedures, the research must not be greater than minimal risk. Collecting blood samples in healthy populations and within certain amounts qualifies for an expedited review. A full review is necessary when research poses more than minimal risk to subjects or anytime a vulnerable population is studied. Studying how a new medical treatment or clinical procedure affects blood pressure in children (a vulnerable population) requires a full review. An Ongoing Issue Long after the enactment of numerous rules and regulations surrounding medical research, ethical breaches have occurred. The Gelsinger case at the University of Pennsylvania is a recent example of a severe violation of ethics. In 1995, an experienced and respected researcher designed a study that used a genetically engineered cold virus that had previously only been tested in animals to deliver genes to correct a genetic liver disorder in humans. After receiving Institutional Review Board approval, the study commenced. The subjects were stable adult clients with the specific, identified genetic liver disorder. Jesse Gelsinger, an 18-year-old client, was the next-to-last subject enrolled in the study despite reports expressing concern about the safety of the cold virus. Unfortunately, Gelsinger received a dose of the virus that was Matching: Beneficence dictates the researcher’s obligation not to harm the research participants but also to maximize the possible benefits. If data can be collected in any way that poses less risk to participants, the researcher must consider alternate options. Justice demands equal treatment and fairness for all research subjects. No person should be unfairly excluded from a study without good reason. Respect for persons is based on autonomy. Research subjects must consent to voluntary participation after receiving all information about the study. The Common Rule lists specific vulnerable groups: children, prisoners, pregnant women, fetuses, mentally disabled persons, and economically and educationally disadvantaged persons. Healthcare workers are not considered a vulnerable population and are often the subjects of medical research. Subjects are not considered vulnerable based on race, ethnicity, or spiritual beliefs. Research is defined as a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalized knowledge. To be considered research, the activity must be characterized by systematic investigation and the primary goal is to develop or contribute to generalizable knowledge. related to client management, practice management, and health policy decision- making. All three elements are equally important. Controlled trials may be one of the types of research conducted to obtain evidence and practice recommendations. Medical evidence focuses on scientific studies that quantify causes of disease and effects of treatment. Nursing often requires a broader range of evidence, a holistic approach, that includes physical, psychosocial, and spiritual needs. Blinded peer review is completed by a neutral party who does not know the author(s). Replicated review is when multiple parties repeat a review. Peer review is an appraisal, but the reviewer could have a connection to the author. Blinded nursing research occurs before the final report is complete and is done by the author, who is not aware of which client is receiving which intervention. Incorporating Evidence In which ways can evidence be incorporated into nursing practice? Select all that apply. Evidence can be incorporated by synthesizing findings into practice guidelines (developing a policy and procedure), exploring and describing health phenomena (discovering changes in health trends), finding solutions to existing health problems, and identifying new treatment options. Confirming treatment options are effective would be the evaluation of the integration of evidence. A unit needs to identify how the staff feels about the department and the clinical concern. Staff should review client satisfaction scores. Leadership could verify the education of staff and their on-the-job training about the topic, verify client satisfaction scores, and review policies and procedures on the issue. The equipment condition is critical to identify if anything related to technology could cause a problem or if there is new equipment available. Credibility The most credible research studies have which characteristic? An author who has experience in the field provides credibility to the study. The number of references and the level of wording does not apply to credibility. An author who has a stake in the treatment being tested would present a potential bias. A co-worker reviewing a colleague’s work would be a peer review. identify ways to improve and possibly collaborate with the OR to hear about some of their staffing strategies. Journal clubs meet to appraise and share nursing research with a goal of learning and finding evidence for practice. This allows nurses to synthesize findings into practice guidelines and policies. They can discuss and find solutions to existing or new problems. They can also share their new knowledge beyond the journal club to benefit the entire staff. Though nurses can participate in the research process by collecting feedback on prenatal class benefits from clients after delivery or assisting with chart audits, these are not goals of a journal club. It is not always easy to determine if a publication is peer reviewed. If the journal does not explicitly state that it is peer reviewed at the beginning of the journal, the nurse should further investigate its website or publication information rather than automatically exclude it as not being a scholarly one. Introduction to Nursing Research and Evidence-Based Practice Ethical principles for nursing research are in many ways the natural extension of ethical principles for professional nursing practice. Ethics is often defined by what is right versus what is wrong. Whether planning research or reading research, understanding and applying ethical principles is an important element of ensuring the highest quality client care. Ethics in Research Evidence Based Practice-Schn This concept will review some key ethical situations in history and discuss how nurses support nursing research and uphold these ethical principles. Fabrication is the intentional misrepresentation or "making up" of data or results by a researcher. Falsification is when the data is manipulated, procedures are changed, or when subjects are accepted into the study that don't fall under the proper criteria. Plagiarism is connected to the written account of the research when ideas, statement results, or words are not attributed to the appropriate person, but rather linked to the writer's own works. Infringement is when a copyrighted work is reproduced, distributed, performed, publicly displayed, or made into a derivative work without the legal permission of the copyright owner. Respect for persons: Right to voluntary participation after informed consent. Beneficence: Do no harm – protecting one's well-being. An act of charity, mercy, and kindness with a strong connotation of doing good to others, including moral obligation. Justice: Right to fair treatment and fairness in distribution of benefit and burden. “SARS-CoV-2 is a potentially deadly virus. Providing misinformation to the public regarding masking, vaccines, medications and/or COVID- 19 threatens public health. Misinformation, which is not grounded in science and is not supported by the CDC and FDA, can lead to illness, possibly death, and may prolong the pandemic. It is an expectation of the U.S. boards of nursing, the profession, and the public that nurses uphold the truth, the principles of the Code of Ethics for Nurses (ANA, 2015) and highest scientific standards when Control and Prevention (CDC) and the Food and Drug Administration (FDA) (NCSBN, 2021). After learning about the scope and standards of practice and the code of ethics, we know that nurses are expected to practice using the best available evidence to promote safe and quality client care using clinical judgment to address complex situations. References American Nursing Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. National Council of State Boards of Nursing. (2021, December 2). Dissemination of non-scientific and misleading COVID-19 information by nurses [Policy statement]. https://www.ncsbn.org/PolicyBriefDisseminationofCOVID19Info.pdf Code of Ethics Provision 7 Though different documents, the ANA “Scope and Standards of Practice” and the “Code of Ethics” are closely related. Since we just discussed the standards of education and scholarly inquiry, let’s review Provision 7 of the code of ethics. Provision 7 requires that nurses study research and use scholarly inquiry to advance the profession (Fowler, 2015). disseminating information about COVID-19 or any other health-related condition or situation." "When identifying themselves by their profession, nurses are professionally accountable for the information they provide to the public. Any nurse who violates their state nurse practice act or threatens the health and safety of the public through the dissemination of misleading or incorrect information pertaining to COVID-19, vaccines and associated treatment through verbal or written methods including social media may be disciplined by their board of nursing. Nurses are urged to recognize that dissemination of misinformation not only jeopardizes the health and well-being of the public but may place their license and career in jeopardy as “The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy” (Fowler, 2015, p. 113). Reference Fowler, M. D. (2015). Code of ethics for nurses with interpretive statements (2nd ed.). American Nurses Association. Contributions through Research and Scholarly Inquiry The nurse must engage in scholarly activity by providing evidence- informed practice. Clients must be protected through each step of the research process. Contributions through Research and Scholarly Inquiry Contributions through Developing, Maintaining, and Implementing Professional Practice Standards Contributions through Nursing and Health Policy Development Reference Henderson, V. (1978). The concept of nursing. Journal of Advanced Nursing, 3(2). https://doi.org/10.1111/j.1365-2648.1978.tb00837.x The Standards of Practice describe a competence level of nursing practice demonstrated by the critical thinking model known as the nursing process. The nurse process forms the foundation of nursing decision making. There are 6 standards of practice: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The Standards of Professional Performance describe a competent level of behavior in the professional role. All nurses are expected to engage in professional role activities reflective of their education, experience, and position and are accountable to themselves, clients, peers, and society. There are 12 standards of professional performance: ethics, advocacy, respectful and equitable practice, communication, collaboration, leadership, education, scholarly inquiry, quality of practice, professional practice evaluation, resource stewardship, and environmental health. The Code of Ethics incorporates 9 provisions that assist the nurse in managing ethical dilemmas and moral distress. Provision Component Nurse Behavior RationaleContributions Through Research and Scholarly Inquiry A nurse is piloting a new fall prevention program for surgical clients based on new research. Each client is informed of the pilot program. The nurse must engage in scholarly activity • Understand the nurse’s role related to Advance Directives for Healthcare • List the elements needed to establish negligence • Analyze nursing actions associated with a breach of nursing practice A living will directs the client's healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time. Statutory law: Legislation passed by US Congress and state legislatures that is civil or criminal. Civil law: Protect the rights of individuals by settling disputes between citizens. Nurse Practice Acts: Define nursing standards that must be met within individual states. Criminal law: Defines offenses and punishments for those who threaten, harm, or endanger society. Case law: Decisions made based on previous court cases. The relationship between an individual seeking health care and the professionals providing that care is based on trust. The individual trusts the health professional to provide care that is needed in a manner that is safe and inform them of the risks and benefits of the care recommended, as well as alternative options. The health professional trusts individuals in their care to be honest when providing information, remain an active partner in their care, and follow prescribed treatments. State laws define who is able to provide consent for care, and the nurse is responsible for knowing the laws for the state in which they practice and the policies of their employer regarding consent. In general, consent for health care can be provided by competent individuals over the age of 18 and emancipated minors, as described below. The issue of emancipated or unemancipated minors does not relieve the health care provider's duty to attempt to obtain meaningful informed consent. For clients who are hearing impaired, unable to read, and those whose primary language is not English the health care provider is required to provide the consent information in a manner the client can understand. These accommodations may include printed materials in the client’s preferred language, audio or visual information, or a certified medical interpreter and must be provided at no cost to the client. Who Can Provide Consent for Medical Care? Consent for Health Care can be Provid Adults A. Any competent individual 18 years of age or older for themselves. B. Any parent for their uneman- cipated minor. C. Any guardian for their ward. D. Any adult for the treatment of their minor brother or sister (if an emergency and parents are not present). E. Any grandparent for a minor Yb E grandchild (in an emergency a= and if parents are not present). a § Minors A. Ordinarily minors may not consent to medical treatment without a parent. However, emancipated minors may Z = consent to medical treatment without a parent i ;AAA (Potter, 2017, p. 309). Emancipated minors include: iy =E] ~ \\inors who are designated emancipated by a court ¢ —= Video View the Cruzan, Schaivo, and the Importance of Healthcare Planning video to learn more about the evolution of an individual’s rights to self-determination. • Provide educational programs for staff, clients, and the community on ethical issues concerning client self- determination and advance directives As a result of these rulings, Advance Directives for Health Care, often referred to as living wills, have become the legal documents by which individuals can clearly convey their wishes for care. Components of Advance Directives Living Will A living will is a legal document used by an individual to make their preferences for future health care decisions if they are unable to make the decisions them self. The living will is only used at the end of life if a person is terminally ill (can't be cured) or permanently unconscious. The living will describes the type of medical treatment the person would want or not want to receive in these situations. It can describe under what conditions an attempt to prolong life should be started or stopped. This applies to treatments including, but not limited to dialysis, tube feedings, or actual life support (such as the use of breathing machines). Before the health care team can follow a living will to guide medical decisions, two physicians must confirm that the client is unable to make their own medical decisions and is in a medical condition that qualifies as terminal illness or permanent unconsciousness in their state. Information in a living will typically address care decisions that address both the quality and quantity (length) of life. • The use of equipment such as dialysis machines (kidney machines) or ventilators (breathing machines) to help keep the client alive. • Do not resuscitate orders (instructions not to use CPR if breathing or heartbeat stops). • The use of fluid or liquid (usually by IV) and/or food (tube feeding into the stomach) if the client is unable to eat or drink. • Treatment for pain, nausea, or other symptoms, which may be called comfort care or palliative care. • Potential donation of the client’s organs or other body tissues after death. It is important to know that a client’s choice not to have aggressive medical treatment is different from refusing all medical care. A person can still get treatments such as antibiotics, food, pain medicines, or other treatments. It is just that the goal of treatment becomes comfort rather than cure. The client may end or take back a living will at any time. Durable Power of Attorney for Health Care A durable power of attorney for health care (DPOA), also known as a medical power of attorney, is a legal document that names a person to be a proxy (agent) to make health care decisions for an individual who has become unable to do so them self. Before a DPOA can be used to guide medical decisions, a person's physician must certify that they are unable to make their own medical decisions. Once enacted, the DPOA allows the client’s proxy to speak with the health care team and other caregivers and make decisions according to the wishes or directions outlined in a Living Will or previously communicated in person. If the client’s wishes in a certain situation are not known, the proxy will make a decision based on what they believe the client would want. If the client regains the ability to make their own medical decisions, the proxy cannot continue to make medical decisions on their behalf. Durable power of attorney laws vary from state to state. It is important that the nurse be familiar with the laws for the state in which they work. Organ and Tissue Donation Advance health care directives and informed consent remain the cornerstones of clients' right to self-determination regarding medical care and preferences at the end-of-life. However, the effectiveness and clinical applicability of advance health care directives to decision-making on the use of life support systems at the end-of-life is questionable (Verheijde et al., 2007). One complex issue that may arise when an individual completes an Advance Directive involves organ and tissue donation. Though organ and tissue donation can be included in the advance directive, individuals who request that life support systems be withheld limit which organs or tissues can actually be used in donors awaiting transplants. The Uniform Anatomical Gift Act (UAGA), was revised in 2006 to permit the use of life support systems at or near death for the purpose of maximizing procurement opportunities of organs medically suitable for transplantation, overriding advance directives on utilitarian grounds, which is a serious ethical challenge to healthcare and society (Verheijde et al., 2007). For this reason, it is imperative that health professionals and hospitals fulfill their responsibilities to educate clients on how temporary use of life support systems can be used to support organ donation. With this knowledge the client is better prepared to determine their end-of-life choices, share them with loved ones, and accurately document their preferences. Legal Aspects of Providing Care A crime is an act, or failure to take action, that breaks a criminal law. Refusing to provide healthcare information to a client’s child, reporting suspected abuse, and completing employer required documentation are not acts that violate a law. Nor do they violate the civil law that governs the interactions between two parties that results in harm to one of the parties. Inappropriate delegation violates civil, but not criminal, law. Taking or selling controlled substances that are diverted from clients for whom they were prescribed and physically restraining a client without a prescription are violations of both civil and criminal law. Legal Aspects of Providing Care Malpractice, one type of negligence, involves injury to a client resulting from the failure of the health professional to provide the expected level of care required by the profession For nurses, malpractice includes: • Failure to assess and/or monitor, including making a nursing diagnosis. • Failure to observe, assess, correctly diagnose or treat in a timely manner. • Failure to use, calibrate, or replace equipment required to safely care for the client. • Failure to document care and evaluation of care provided to the client in a timely manner. • Failure to notify the healthcare provider of significant changes in a client's status. • Failure to respond to or correctly implement new and existing orders. • Failure to follow the six rights of medication administration. • Failure to convey discharge instructions to the client, his or her family, or providers who are assuming responsibility for the client. • Failure to ensure client safety, especially clients who have a history of falling, are sedated or confused, are frail, are mentally impaired, get up in the night, or are uncooperative. • Failure to follow policies and procedures. • Failure to properly delegate and supervise. Breach of Duty In this situation, the nurse failed to document or report a significant change in the client’s condition. Individuals who are placed in a plaster cast immediately after the injury occurs Reporting Abuse Here is the correctly ordered list. 1. Assess the newborn. 2. Establish nursing diagnosis and outcomes of care for the newborn. 3. Assess the parent’s knowledge of caring for the newborn. 4. Provide teaching as needed. 5. Document visit. 6. End the visit. 7. Contact the nursing supervisor to report the suspected abuse of the 2-year-old. Although the nurse is in the home to care for the newborn, it is reasonable for them to make observations about others living in the same home. Since the appearance of the 2-year-old and the statements by the parent may indicate abuse, the nurse is obligated to report the incident as outlined by their employer. At this time, the toddler does not appear to be in immediate danger, so the nurse will contact the supervisor after caring for the newborn. To continue the visit, the nurse will focus on the client by applying the nursing process and clinical judgement. The nurse will discuss and document the client’s concerns and desires for their care and treatment, relay the information to the healthcare provider, encourage the client to consider assigning a DPOA, and help the client locate assistance with completing an advance directive for healthcare document. The insurance company is not involved with the creation of an advance directive and psychological testing is not required prior to it’s creation unless the healthcare provider is unsure of the individual’s capacity to make healthcare decisions. Helping Others in an Emergency Good Samaritan Laws Offer legal protection to people who voluntarily provide reasonable assistance to those injured individuals first enacted to protect healthcare professionals who assist in emergencies outside their place of employment. Identifying Malpractice To meet the requirements of medical negligence, the injured party must be able to prove that the health professional had a duty to provide care and that the duty was breached or broken. Because an injury may result from various causes, the injured party must also prove that the breach of duty caused the injury. Damages are assigned after the first three elements have been met (Ronquillo et al., 2020). To prevent malpractice, the nurse should follow the standards of care, establish a therapeutic relationship with those in their care, and work cooperatively with the healthcare team. The provision of competent care requires the nurse to be knowledgeable of their employer’s policies and procedures as well as remaining current on advances within their area of practice. Reference Ronquillo, Y., Pesce, M.B., Varacallo, M. (2020, August 15). Tort. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441953/ Each of these clients should be advised to create both a durable power of attorney for health care (DPOA) and living will, and have a conversation with their family and/close friends about the client’s ideas of how they want to live and, when the time comes, die. The nurse who encourages and supports this important conversation is acting as an advocate for the client. Health Care Inequities References Centers for Disease Control and Prevention. (2017, January 31). Health disparities. https://www.cdc.gov/aging/disparities/index.htm PBS NewsHour. (2020, April 2). COVID-19 may not discriminate based on race— but U.S. health care does [Video]. YouTube. https://youtu.be/U5QdRwflM9I United States Census Bureau. (2011, March 24). News releases: 2010 census shows America's diversity. https://www.census.gov/newsroom/releases/archives/2010_censu s/cb11- cn125.html Barriers to Accessing Health Care For people who live with one or more health disparities, getting health care is difficult. Health disparities are impacted by the following factors. Without routine, preventative care, people facing health disparities may develop complex alterations in health, such as asthma, diabetes mellitus, hypertension, or obesity that go untreated until complications of the diseases occur. Those with pre-existing conditions are more likely to be sicker and require cost-intensive, high-tech care. Income Education Gender Race Sexual Orientation Disabilities Geographic Areas Immigrant Status Review the Reaching for Health Equity (CDC, 2016) infographic to learn more about health equity. Health Equity and Social Justice In the United States and across the globe, access to quality health care is often dependent on the social standing and economic resources of the individual. Across socioeconomic classes, access to health care providers and health care facilities often leaves the poorest without preventative services and resources to identify and/or treat acute and chronic illnesses. This leaves many individuals with complex alterations in health (e.g., diabetes mellitus, cardiovascular disease, etc.), at risk for complications of their condition that may have been prevented. These complications are often debilitating and life-threatening, requiring high-cost care in emergency departments and critical care units. Nurses witness the inequity of access to health care (health disparities) daily. It is often apparent to health professionals that health inequality follows the path of social injustice. In fact, health equity itself is the hallmark of social justice in health care because it focuses on reducing health disparities, striving for everyone in society to have the same opportunity when it comes to attaining the greatest level of health. It is with that ideal that health equality equates to social justice, and that nurses should approach each client in their care, particularly those with complex alterations in health with health disparities. The goal of the nurse is to deliver individualized health care with respectful consideration of the person. Reference Centers for Disease Control and Prevention. (2016). Strategies for reducing health disparities. https://www.cdc.gov/minorityhealth/strategies2016/ Click on each + to learn more. a Key Steps in the Resolution Ask the question, Is this an ethical dilemma? ”) Gather information relevant to the case. e Client, family, institutional, and social perspectives are important sources of relevant information. tinguish among fe opinion, and valu a e Negotiation requires a con- fidence in one’s own point of view and a deep respec for the opinions of others. It is never pleasant to be forceful like this. Even though I know it must be done to avoid a life-threatening situation, it still feels somewhat like abuse. Still, in order to avoid further damage I normally give sedative Within the patient’s bill of rights, an individual seeking health care is afforded the right to make decisions about the plan of care prior to and during the course of treatment, including the right to refuse care, even during a medical emergency. Due to the life-threatening aspect of acute, complex illness, nurses who work with these clients are often involved in the decision-making process. When the final decision of the client differs from what the nurse would choose personally, the nurse faces an ethical dilemma. Bull and Sørlie (2016) categorize the ethical dilemmas faced by nurses as below. • making decisions on behalf of the client • trying to influence the client’s decision • assisting the client to decide One example of making decisions on behalf of clients is using sedation to prevent interruption of treatment, such as mechanical ventilation, intravenous (IV) medications, or cardiac monitoring. Legal Aspects of Complex Health Care Support for Ethical and Legal Dilemmas Reference Bull, E. M., & Sørlie, V. (2016). Ethical challenges when intensive care unit patients refuse nursing care: A narrative approach. Nursing Ethics, 23(2), 214–222. https://doi.org/10.1177/0969733014560931 When the ethical and legal choices faced by nurses do not “feel right,” that may indicate that the client’s rights are being violated. That same feeling may also indicate that the nurse’s personal beliefs are being challenged more than the client’s personal rights. Seeking input from Nurses should take care of themselves and their colleagues. The first step is to recognize the symptoms of moral distress, whether in themselves or others. Recognizing Moral Distress These symptoms may be physical, emotional, behavioral, or psychological in nature, including: • headaches • palpitations • gastric upset • anger • guilt • frustration • withdrawal • depression • burnout leaving the nursing professionAfter recognizing moral distress, nurses can discuss the situation, how it occurred and what they would do differently if in a similar situation in the future, with their colleagues. For ongoing self-care, designating a spot for staff to sit, uninterrupted, can provide anyone with a place to relax and clear their minds. More formally, nurse managers may schedule a debriefing session “to provide closure, alleviate signs and symptoms of acute distress, and assess the need for individual follow-up” (American Association of Nurse Anesthetists, 2014, p. 4). Many employers also have an employee assistance program that provides help to nurses who, while providing care, are emotionally traumatized. Responding to Moral Distress Remember: Not everything that weighs you down is yours to carry. —Juansen Dizon Recognizing and Responding to Moral Distress Reference American Association of Nurse Anesthetists. (2014). Guidelines for critical incident stress management [PDF]. https://www.aana.com/docs/default- source/practice-aana-com- web-documents-(all)/professional-practice- manual/guidelines- for-critical-incident-stress-management.pdf? sfvrsn=ba0049b1_4 The nurse is caring for a 45-year-old client who is dependent on a ventilator after a high cervical neck injury. Although the client is under the Advance Directives and Do-Not- Resuscitate Orders care of the health care team and the family, the client has decided to stop using the ventilator, which will lead to death. The nurse believes the client is committing suicide and would prefer the client to choose differently, but the nurse says nothing. The nurse remains at the bedside, offering support to the client and family as the ventilator is turned off and the client dies. The nurse does not work for the next three days due to insomnia, loss of appetite, and severe headaches. What is the best action for the nurse’s manager to take in order to help this nurse? The nurse manager should reach out to discuss and determine if the nurse’s symptoms are a result of the situation in which the client’s values and actions differed from those of the nurse. While the nurse remained professional and stayed to provide compassionate care by setting aside their own values and beliefs, the conflict between what they believe is right and their actions could cause moral distress. Nurse managers have responsibility for caring for their staff. Doing nothing is not the right action. Encouraging other nurses to take food to the nurse prior to assessing why the nurse is not at work is not the best action, either. Managers cannot place an employee on leave unless the employee requests that. As with any person seeking care, those with complex alterations in health have the right to autonomy and self-determination even when they cannot speak for themselves. In many facilities, the individual responsible Nurse Responsibilities • Accept that if the DNR form is not available and the client cannot confirm their wishes, resuscitative must be provided. • Should an active DNR be discovered during resuscitation efforts, notify the health care provider and nursing supervisor. • Confirm the validity of the DNR form and the identity of the client. • Withhold or withdraw resuscitative measures upon finding a valid DNR form. • Provide palliative and supportive treatment for the client and family. Client or Fa Determine if the client has a terminal condition and the capacity to provide consent. Accept that if the DNR form is not available and the client cannot confirm their wishes, resuscitative care must be provided. X Provide palliative and supportive treatment for the client and family. Confirm the validity of the DNR form and the identity of the client. Participate in care to the extent they are able. X Withhold or withdraw resuscitative measures upon finding a valid DNR form. Provide an original, unaltered DNR form for the health care team. X Client or Fa Understand the consequences of refusing resuscitative measures. X Upon enactment of the DNR order, the client and their family partner with the health care team to ensure that life-saving treatments are stopped and supportive care, even if it will hasten death, continues. While some responsibilities fall to specific team members, it is the responsibility of the nurse to advocate for the client and family, as needed, while providing quality care that eases the transition for the client. Rapid Response Team In hospital cardiac arrests (IHCA) are associated with negative outcomes and poor survival despite the quick intervention of health professionals (Dukes et al., 2019). Since individuals often show early and subtle signs of deterioration (e.g., mild confusion, tachypnea, vital sign changes, etc.) 6 to 8 hours before cardiac or respiratory arrest, early identification and treatment can prevent IHCA (Jackson, 2017). Rapid response teams (RRTs) were developed to prevent IHCA by bringing rapid care to unstable patients in noncritical care settings. RRT intervention has made significant advances in reducing mortality rates in these clients (Institute for Healthcare Improvement, n.d.; Jackson, 2017). Transcript References Dukes, K., Bunch, J. L., Chan, P. S., Guetterman, T. C., Lehrich, J. L., Trumpower, B., Harrod, M., Krein, S. L., Kellenberg, J. E., Reisinger, H. S., Kronick, S. L., Iwashyna T. J., Nallamothu, B. K., & Girotra, S. (2019, July 29). Assessment Rapid Response Team Based on the information below, determine if each client requires the intervention of a rapid response team (RRT) or not. Use the drop-down menu to specify activating or not to activate the RRT. RRT ResponseClient InformationReasonActivate RRTA 23-year-old was admitted to a surgical unit with right lower quadrant pain and nausea. Half an hour (30 minutes) after receiving intravenous (IV) pain medication, the client’s heart rate dropped to 30 beats/minute and the client became unresponsive.This client is experiencing adverse effects of the IV pain medication.Do NOT activate RRTA 68-year-old was admitted to an intensive care unit with new onset confusion and left-sided weakness.RRTs provide care in noncritical care areas.Do NOT activate RRTA 44-year-old with stage IV cancer and a do-not- resuscitate (DNR) order is receiving palliative care on the oncology unit who becomes pulseless in the middle of the night.This client has a DNR order which specifies no life-saving measures are to be done.Activate RRTThe spouse of a 55-year- old client notices changes in the client’s behavior that tend to occur prior to the client’s heart rate slowing and blood pressure falling, but the nurse appears not to be concerned.Because the spouse knows the client well, their “gut feeling” is an early warning sign of the client’s status change and should be acted upon.Do NOT activate RRTA 33-year-old client admitted for surgical repair of an open fracture of the left femur is discovered pulseless and not breathing.A code blue should be activated instead. Many hospitals use a different team for cardiac arrest. Ethical and Legal Dilemma A distraught client informs the nurse that they want a new health care provider (HCP) because their current HCP refuses to write a do-not-resuscitate (DNR) order as the client has requested. What is the best action for the nurse to take at this time? Recognizing Cues: Clinical Deterioration The nurse recognizes this situation as both an ethical and legal dilemma. The nurse should begin by gathering information and then sharing that information with the nursing supervisor for further directions. Based on the documented information, the client’s first indication of clinical deterioration was discovered at 17:45 (tachycardia, restlessness, and anxiety). The nurse should have notified the surgeon at 17:45 and activated the rapid response team (RRT) at 18:20 when the symptoms escalated, and the client began hallucinating. Since individuals often show early and subtle signs of deterioration (e.g., mild confusion, tachypnea, and/or vital sign changes) 6 to 8 hours before cardiac or respiratory arrest, early identification and treatment can prevent complications (Jackson, 2017). Reference Jackson, S. (2017, December). Rapid response teams: What’s the latest? Nursing2021, 47(12), 34–41. https://doi.org/10.1097/01.NURSE.0000526885.10306.21 The nurse is caring for a client with pneumonia. Click on each tab below to review the electronic health record (EHR), and answer the question. • Based on the client’s admitted diagnosis and history of lung cancer, the changes in the client’s respiratory status should concern the nurse