Week 6, 7, 8

acute vs chronic illness

chronic illness

gradual onset of symptoms

• symptoms ma be mild or vague: once illness is resolved may have remissions and exacerbations

• illness continues throughout the life span and changes are permanent and progressive

• requires long term behavioral change / treatment

• often represents a life crisis

examples of chronic illnesses

• hypertension

• diabetes

• arthritis

• cancer

• COPD

• coronary heart disease

acute illness

characterized by severe symptoms that are relatively short-lived. (a personal experience)

• sudden onset of symptoms that progress quickly from mile to severe

• patient usually returns to former level of functional / changes are often not permanent but may progress to chronic illness

• does not usually require long term behavioral change / treatment

examples of acute illnesses

• common cold

• acute appendicitis as potentially life threatening

• acute myocardial infarction leading to chronic conditions

• spinal cord injury and life changes

lifestyle risks of chronic disease

1. tobacco use

2. poor nutrition

3. lack of physical activity

4. excessive alcohol use

5. aging population

adjusting to illness is a process

People typically experience adjustment to illness in stages:

• disbelief and denial,

• irritability and anger,

• attempting to gain control,

• depression and despair

• acceptance and participation

it may not be a linear process and is subjective

disbelief and denial

• People have difficulty believing that signs and symptoms are caused by illness.

• They may believe that the symptoms will go away.

• Fear of illness often leads to the mistaken belief that the symptoms will subside without treatment and can delay seeking a diagnosis.

• Denial is a psychological defense mechanism that people sometimes use to avoid the anxiety associated with illness

irritability and anger

• Some patients get irritable as their ability to function declines.

• Prolonged irritability may be an indication that the patient is depressed.

• Anger may be directed at specific people or simply be general—“mad at the world.”

  • Anger may also be directed toward others—spouse, family members, co-workers, or health care providers.

  • Anger may be directed inward, and guilt feelings may occur for failing to prevent the illness

attempting to gain control

• People may consult their health care provider or use over-the-counter medications, folk practices, or home remedies.

• They are aware that they are ill and usually experience some concern or even fear about the outcome.

• These fears usually stimulate treatment - seeking behavior as a way of gaining control over the illness, but fears may also lead to further denial and avoidance.

depression and grief

Grief—the normal and expected response to any loss, including one’s health

Depression—a treatable mental health condition.

The ability to work is altered, daily activities must be modified, and the sense of well-being and freedom from pain may be lost.

acceptance and participation

• The patient has acknowledged the reality of illness and may be ready to participate in decisions about treatment.

• Active involvement and the hope attached to pursuing treatment usually lead to increased feelings of mastery of the illness.

• Patients with long-term chronic illnesses become experts in their own care and management of their condition.

internal influences on illness behaviors

• Dependence and independence

• Coping ability – coping = strategies used to assess/manage demands

• Resourcefulness - using cognitive skills to adapt to the world, often in very creative ways

• Resilience – the capacity to recover quickly from difficulties

• Spirituality – commonly related to belief in a higher power, interconnectedness among living beings, an awareness of life's purpose and meaning.

3 branches of government

1. legislative

2. executive

3. judicial

legislative

makes laws

• congress

  • senate

  • house of representatives

executive

carries out laws

• president

  • vice president

  • cabinet

judicial

evaluates laws

• supreme court

• other federal courts

laws

rules of conduct that are authored & enforced by formal

authorities & hold people accountable for compliance.

common law

decisional, judges rulings become law, laws developed through judges' decisions in court cases.

• Judges make decisions based on previous court cases.

• These decisions can become legal precedents that other courts follow.

statutory law

established through formal legislative processes, laws created by lawmakers through the legislative process.

• Created by Congress or state legislatures.

• These laws are officially written and passed.

administrative law

delegated authority to government agencies, rules and regulations created by government agencies.

• Government agencies receive authority to create and enforce regulations.

• These regulations help carry out laws passed by legislators.

civil law

recognized and enforces the rights of individuals in disputes over legal rights or duties of individuals in relation to one another, laws that protect individuals' rights and resolve disputes between people or organizations.

• Usually involves someone claiming their legal rights were violated.

• Often results in financial compensation rather than jail time.

criminal law

involves public concerns regarding an individual’s unlawful behavior that threatens society; laws that deal with actions considered crimes against society.

• Involves illegal behavior that threatens public safety.

• Punishment may include fines, probation, or imprisonment.

sources of law: statutory

law that is established by legislatures that people must follow, or a law that is formally written and enacted.

• Federal statutory law: must be followed by every state

• State and local statutory law: laws for a particular state or community, may be needed when there is no federal statute (cannot conflict with federal law)

• Federal, state, and local statutory laws must be constitutional. Supreme Court may overturn a statutory law if it is deemed unconstitutional

• Examples: Civil Rights Act of 1964, the Voting Rights Act of 1965

federal statutory law

• Laws created by the U.S. Congress.

• Apply throughout the United States.

• Every state must follow applicable federal laws.

sources of law: administrative

rules and procedures that are in place to administer or enforce statutory laws; protects the public

• Developed by regulatory agencies at the federal and state levels

• Examples:

  • Federal: FDA, Medicaid

  • State: Division of Consumer Affairs, Division on Civil Rights

sources of law: case

created from court decisions that are based on a judge’s interpretation of the constitution, a statute or a regulation (developed through decisions made by judges in previous court cases)

• Based on precedent: a ruling in one case is used in subsequent cases

• When using case laws, the court must decide if the law is still relevant, so case laws can be revised or changed

• A case law can be appealed on it’s relevance

• Case laws are both criminal and civil

types of case laws

1. civil

2. criminal

civil laws

governs how individuals relate to others in everyday matters, Laws that protect people's individual rights and settle disputes between individuals or organizations (involves negligence, malpractice, or violations of someone’s rights)

two types:

1. tort laws

2. contract laws

tort laws

law deals with situations where someone causes harm or injury to another person.

• Protects people from harm caused by others.

• Harm can be intentional or unintentional.

• The injured person may sue for financial compensation.

• Common in nursing because it includes negligence and malpractice

• intentional vs. unintentional

negligence

A nurse forgets to put a patient's bed in the lowest position, and the patient falls and gets injured.

malpractice

A nurse fails to meet professional standards of care, causing harm to a patient.

assault

A nurse threatens to give a patient an injection against their will, causing the patient to fear immediate unwanted contact.

threat alone = assault

battery

A nurse intentionally performs a procedure on a patient without valid consent.

any unauthorized physical contact = battery

intentional tort

Deliberate action that violates someone's rights

1. assault

2. battery

3. false imprisonment

4. defamation of character

5. fraud

6. invasion of privacy

false imprisonment

restraining a patient who wants to leave the hospital without a provider’s order or proper justification.

slander

Verbally telling others that a patient has a contagious disease when it’s not true.

• defamation through spoken word

libel

Writing in a patient’s chart that they are “drug-seeking” without medical evidence.

• defamation in written form

breach of privacy / confidentiality

Sharing a patient’s diagnosis or posting about their care on social media.

• Violates HIPAA and ethical principles.

unintentional tort

usually result from negligence, unintended acts that cause harm; the intent is not to cause harm (harm caused by failure to use reasonable care)

1. malpractice

2. negligence

3. failure to communicate

4. failure to asses / monitor

contract law

deals with legally enforceable agreements between two or more parties.

• A contract is an agreement that creates legal obligations.

• Each party is expected to fulfill their responsibilities.

• If someone fails to follow the agreement, it may be considered a breach of contract.

• Contracts can be written or verbal, although some must be in writing

• employment contract vs breach of contract

employment contract

A nurse signs an agreement to work for a hospital under specific employment conditions.

breach of contract

A hospital or nurse fails to fulfill a legally enforceable obligation in their employment agreement.

failure to communicate

Not reporting a patient’s critical lab result to the provider.

• Delayed intervention can lead to harm

failure to assess / monitor

ignoring changes in vital signs post-surgery.

• leads to missed deterioration in the patient’s condition

assault definition

is a threat or an attempt to make bodily contact with another person without the person’s consent

battery definition

is the assault carried out; the impermissible, unprivileged touching of one person by another.

criminal laws

protect society from harmful acts. Distinguished by the seriousness of the act and the resulting punishment

two types

1. felonies

2. misdemeanors

felonies

murder, robbery, rape, kidnapping, possession of a controlled substance with intent to distribute

misdemeanors

theft, traffic violations, possession of a controlled substance

nursing licensing

To protect the public health, safety, and welfare

nursing practice act

Defines and controls nursing

state boards of nursing

regulatory bodies

objectives of nurse practice act

• Defines the practice of professional nursing.

• Describes the authority, power, and composition of Board of Nursing.

• Defines educational program standards.

• Sets the minimum educational qualifications and other requirements for licensure.

• Determines & protects the legal titles & abbreviations nurses may use.

• Provides for disciplinary action of licensees for certain causes

statutory authority of state nursing practice acts

Legislature establishes and amends laws regarding nursing practice.

The legislature delegates authority to enforce the law to an executive agency—board of nursing.

The board of nursing enforces the laws and publicizes rules and regulations that expand the law.

delegation

Professional nurses may delegate independent nursing activities to other nursing personnel

• Professional RNs retain accountability for acts delegated to another person.

• RN is responsible for determining that the delegated person (delegatee) is competent to perform the delegated act.

• The delegatee is responsible for carrying out the delegated act safely.

• The professional nurse remains legally liable, however, for the nursing acts delegated to others unless the delegate is also a licensed professional whose scope includes the assigned act

five rights to ensure safe delegation

Standards that deligeate responsibility for the RN who is delegating responsibility to unlicensed personnel such as nursing assistants

1. right task

2. right circumstances

3. right person

4. right direction / communication

5. right supervision / evaluation

right task

Is the task appropriate for delegation in a specific care situation?

right circumstances

Is delegation appropriate in this case? Consider the patient’s health status, care delivery setting, complexity of the activity and delegate’s competency, and available resources, and determine any other relevant factors.

right person

Can the nurse can verify that the person delegated to do the task is competent to complete this task?

right direction / communication

Has the RN given clear, specific instructions? These include identifying the patient clearly, the objective of the task, time frames, and expected results.

right supervision / evaluation

Can the RN or other licensed nurse provide supervision and evaluation of the patient and the performance of the task?

informed consent

1. Consent must be given voluntarily.

2. Consent must be given by an individual with the capacity and competence to understand.

3. The patient must be given enough information.

role of the nurse with informed consent

• Unless primary providers, nurses collaborate with the primary provider.

• A nurse may witness a patient’s signing but is not responsible for explaining the proposed treatment.

• The nurse is not responsible for evaluating whether the physician has truly explained the significant risks, benefits, and alternative treatments.

• The nurse is responsible for determining that the elements for valid consent are in place, providing feedback if the patient wishes to change consent, and communicating the patient’s need for further information to the primary provider.

delegations of selected nursing tasks model

types of ethics

(moral philosophy)

• meta ethics

• normative ethics

• applied ethics

meta ethics

which focuses on universal truths, and where and how ethical principles are developed;

normative ethics

which focuses on the moral standards that regulate behaviors

applied ethics

which focuses on specific difficult issues such as euthanasia, capital punishment, abortion, and health disparities

basic concepts in ethics

• values

• morals

• ethics

values

are attitudes, ideals, or beliefs that an individual or a group holds and uses to guide behavior

morals

provide standards of behavior that guide the actions of an individual or social group, and are established rules of conduct to be used in situations where a decision about right and wrong must be made.

ethics

a term used to reflect what actions an individual should take and may be “codified,” as in the ethical code of a profession.

bioethics

is the application of ethical theories and principles to moral issues or problems in health care

moral reflection

critical analysis of one's morals, beliefs, and actions—is a process through which a person develops and maintains moral integrity.

moral distress

is typically described as a response to a situation when nurses are faced with ethical dilemmas but also encounter institutional constraints that limit their actions

ethical principles

are basic and obvious moral truths that guide actions

• As a caring profession, respect for a person is a must

• Nurses must understand ethical principles and be proficient at applying the principles in a meaningful way

• Adherence to ethical principles is an important basis for ethical practice in nursing

• Respect for humans as a function of human dignity is the primary ethical responsibility for nurses in practice.

ethical principles based on human dignity and respect

• Autonomy

• Beneficence

• Nonmaleficence

• The principle of justice

• The principle of fidelity

• Veracity

autonomy

asserts that individuals have the right to determine their own actions and the freedom to make their own decisions

beneficence

is commonly defined as “the doing of good.”

• refers to actions done to benefit others

• Involves being compassionate and taking positive actions for the improvement of patients

• It is the feeling and desire to do only the best things to have positive effects

nonmaleficence

is defined as the duty to do no harm

• is the avoidance of actions that harm others, intentionally or unintentionally.

• It makes sure that professional nurses should never ever act in a way so as not to harm anybody, regardless of any type of request made by the client or patient.

• But, there are certain circumstances where it becomes almost impossible to render only the best of service without imposing any kind of threat. In some situations, nurses can’t avoid ‘doing harm’, or ‘do well’ at the same time

the principle of justice

is that equals should be treated the same and that unequals should be treated differently.

• Care should be equal and fair among patients.

• Justice includes impartiality, equality, and fairness.

• distributive and social justice

the principle of fidelity

refers to faithfulness or honoring one’s commitments or promises.

• When nurses are licensed and become a part of the profession, they accept certain responsibilities as part of the contract with society

• Foundation of nurse-patient relationship

veracity

is defined as telling the truth, or not lying.

• Nurses shouldn’t withhold the entire truth from their clients or patients even when it leads to distress among the patient.

• Truthfulness and confidentiality are used in practice at all times

distributive

implies that nurses should treat every individual equally regardless of gender, age, culture, ethnic group, social standing, economic level, religious belief, medical diagnosis, or other individual characteristics

social justice

implies equal rights to participate and access every aspect of services or goods present in the society irrespective of their individual characteristics

profesional ethics and codes

A code of ethics is a social contract through which the profession informs society of the principles and rules by which it functions.

• Shapes professional self-regulation

• Serves as guidelines to the members of the profession

ex.

• The Nightingale Pledge (1893)

• Nursing Ethics: For Hospital and Private Use (1900)

• ICN Code of Nursing Ethics (1965)

• ANA Code of Ethics for Nurses (1950)

steps in ethical decision making

1. Clarify the ethical dilemma

2. Gather additional data

3. Identify options

4. Make a decision

5. Act

6. Evaluate

ethical dilemma

a moral conflict in which the decision maker experiences indecision because the available choices or alternatives result in conflicting values or ethical principles

deontology

from Greek word deon, meaning “obligation or duty”; an act was moral if its motives or intentions were good, regardless of the outcome.

• Act deontologists determine the right thing to do by gathering all the facts and then making a decision.

• Rule deontologists emphasize that principles guide our actions

Utilitarianism

moral rightness of an action is determined solely by its consequence

• “What makes an action right or wrong is its utility, with useful actions bringing about the greatest good for the greatest number of people”

virtue ethics

Emphasizes the character of the decision-maker.

• Virtues are tendencies to act, feel, and judge that develop through appropriate training but come from natural tendencies.

• Individuals’ actions are built from a degree of inborn moral virtue (Burkhardt and Nathaniel, 2002).

• Virtues may be what separate the competent nurse from the exemplary nurse.

principals

A moral decision- making approach to assess the ethics of research with human subjects

• Uses key ethical principles of beneficence, nonmaleficence, autonomy, and justice in resolution of ethical conflicts or dilemmas.

morals

specific beliefs and behaviors based on personal judgment that are based on a person’s ethics

bioethics

ethics related to health care issues

nursing ethics

ethics related to the nurse patient relationship where the nurse is the main care provider involved in the issue

moral reasoning

making decisions based on morals