Topic 2: Legal and Ethical Foundations of Nursing Practice
Role Relationships and Communication in Nursing
Overall Concept of a Role:
Ascribed Roles: Roles given at birth, e.g., child, Prince Charles (now King Charles).
Acquired Roles: Roles gained through circumstances, e.g., sibling, parent, grandparent, carpool driver.
Theoretical Constructs Related to Nursing:
Social Learning Theory (Related to Learning):
Attention: Giving attention to a preceptor teaching a skill (e.g., inserting a Foley catheter).
Retention: Processing and retaining the information learned.
Reproduction: Being able to reproduce the skill (e.g., inserting a Foley catheter independently).
Motivation: Being motivated to continue and repeat the learned skill.
Metaphor: "Watch one, do one, teach one" (e.g., TB testing).
Role Theory:
Focuses on what is expected based on a certain role.
Nurses are expected to be honest and trustworthy.
Also encompasses an individual's own perception of their professional role (e.g., educator ensuring students have tools for success).
Example: Nurse Ratched from "One Flew Over the Cuckoo's Nest" as an example of abusive and non-therapeutic nursing, contrasted with the expectation of compassionate, caring, and respectful nursing.
Nurses act as patient advocates, speaking up even if a medical provider has a "God complex" (e.g., questioning penicillin order for a patient with an allergy).
Competencies and Regulatory Frameworks for Professional Nurses
Attributes of a Competent Nurse:
Professionalism: Stepping into leadership roles, providing bedside care, implementing change.
Scope of Practice: Varies by state; overall responsibilities of a registered nurse. We will discuss this in detail.
Technology Competence: Familiarity with current and evolving healthcare technology (e.g., electronic charting systems, overcoming initial fears).
Quality Safety Education in Nursing (QSEN): Core competencies for nursing programs, ensuring graduates are competent in quality, safety, leadership, and role clarity (understanding responsibilities, delegation).
Evidence-Based Practice (EBP): Applying current, proven clinical care (e.g., not using alcohol on a newborn's umbilical cord).
Informatics: Utilizing information technology.
Quality Improvement: Continuously improving patient care processes.
All these aspects converge to focus on patient-centered care.
NCLEX:
Established in 1950 by the NLN (National League for Nursing) as the first statewide/national testing for nursing licensure.
Ensures consistent standards across states.
State Legislature's Role:
Passes Practice Laws: Determines what nurses can and cannot do in a specific state (e.g., Utah, Nevada, Arizona).
Purpose: To protect the public's health, safety, and welfare.
State Boards of Nursing's Role:
Enforce Practice Acts: Administer and enforce the laws passed by the state legislature.
Licensure: Licenses nurses after successful NCLEX completion, background checks, and other requirements (e.g., fingerprinting).
Compact States: Allows nurses licensed in one compact state to practice in other compact states without additional licensure (e.g., Missouri license allows practice in Nebraska).
Mandatory Reporting: Nurses are mandated to report concerns regarding a nurse's conduct, performance, or competence. The State Board of Nursing investigates these reports.
Specific State Reporting Requirements: Nurses must be familiar with what their state requires for reporting (e.g., speeding tickets, "dog at large" tickets in Nebraska as unprofessional conduct).
Nurse Practice Roles and Education Trends
Diverse Nurse Practice Roles:
Direct Patient Care Nurse: Entry-level RN providing bedside care in acute settings. May require specialized training (e.g., ACLS for ED, NALS for NICU/PICU) but not an additional degree.
Nurse Managers: May require additional training or a baccalaureate degree (BSN) depending on the facility.
Advanced Practice Registered Nurses (APRNs) / Nurse Practitioners (NPs): Have advanced training and skills, can function as healthcare providers, including prescribing medications.
Clinical Nurse Leader (CNL): Often holds a master's degree, manages patient care at a unit level, or focuses on a clinical specialty.
Clinical Nurse Specialist (CNS): Advanced training and specialty focus (e.g., oncology CNS can round on patients and prescribe for chemo side effects).
Doctor of Nursing Practice (DNP): A terminal degree. DNP-prepared nurses synthesize existing research and apply it to practice.
PhD-Prepared Nurse Researchers/Educators/Scientists: A terminal degree with a focus on generating new knowledge through research and teaching.
Trends in Nursing Education:
Increased Clinical Simulation: Growing use of simulators, evolving significantly from early models (e.g., Grey's Anatomy example from 2006).
Experiential Learning: Hands-on learning followed by reflection and debriefing to facilitate deeper understanding.
Interdisciplinary Education: Multiple professions learning together and collaborating to improve patient care (e.g., nurses, respiratory therapists, providers learning to use new equipment).
Professional Socialization and Benner's Stages
Professional Role Socialization:
A complex, continuous, interactive educational process.
Involves acquiring knowledge, skills, attitudes, norms, values, and behaviors of the nursing profession.
Role Modeling: Learning from experienced nurses (e.g., in behavioral health or obstetrics) about therapeutic communication and handling challenging situations.
Learning from clinical preceptors, mentors, and organizational missions (e.g., hospice care goals).
Distinguishes between "textbook nursing" and "real-world nursing" while emphasizing basic knowledge and appropriate professional behavior.
Steps in Role Socialization:
New Job Orientation: Includes training like TeamSTEPPS (communication in the workplace) and understanding the organization's mission.
Continuing Education: Essential for lifelong learning, staying current with evidence-based practice (e.g., not dumping alcohol on a newborn's umbilical cord).
Strategic Career Planning: Setting goals for future professional development (e.g., five, ten, twenty-five years).
Identifying Role Relationships:
Self-Awareness: Understanding one's own view of their role (e.g., charge nurse responsibilities).
Nurse's Rights: The right to speak up against unsafe care (e.g., inadequate staffing, lack of interpreters, advocating for nurse-patient ratios through organizations like the ANA).
Benner's Stages of Professional Nursing (Stages of Competence):
Novice: Limited or no experience (e.g., new nurse aide learning basic vital signs).
Advanced Beginner/Beginner: Understands basic elements, can organize and prioritize tasks but still needs guidance (e.g., student nurse after first clinical).
Competent: Has 1-2 years of experience, handles familiar situations, but still seeks broader explanations and knowledge for unfamiliar processes (e.g., asking for help with a wound vac).
Proficient: Understands the "bigger picture," confident, performs tasks with speed and flexibility (e.g., during emergency codes).
Expert: High level of skill, intuitive, good grasp of situations, can teach others, recognizes and addresses unexpected events. Not an endpoint, nursing demands lifelong learning.
Work Environment and Patient Advocacy
Factors Impacting Communication and Work Environment:
Staffing Levels: Shortages lead to high nurse-patient ratios (e.g., 9 patients to 1 nurse).
Space: Overcrowding (e.g., patients in hallways).
Organizational Climate: Supportive vs. punitive environments (e.g., being fired for calling in sick).
Open Communication: Ability to report unsafe practices without fear of reprisal.
Collaboration: Working with other nurses and interdisciplinary teams (e.g., nurse aides, LPNs, RNs). The term "unlicensed assistive personnel" (UAP) includes nurse aides and med aides.
Manageable Workloads: Ensuring tasks are feasible for staff.
Magnet Hospitals: A designation reflecting a nursing-friendly culture, supporting continuing education, competence, and nurse autonomy in practice decisions.
Networking Roles: Encouragement to explore other units or jobs within the organization without guilt.
Patient Advocacy:
A primary role of nurses.
Applying social justice practices, respecting patient autonomy (e.g., choosing alternative medicine as long as not harmful).
Ensuring equal access to care.
Advocating for the patient and their family/loved ones as part of the team.
Supporting patient autonomy, decision-making, and goal setting (e.g., individualized steps goals for public health clients rather than a blanket 5,000 steps).
Legal Aspects of Nursing
Nursing as a Regulated Practice: Governed by the U.S. Constitution and legal branches.
The American Legal System:
Common Law (Decisional): Judge-made law based on precedent.
Statutory Law: Formal laws created through legislative processes (e.g., Nurse Practice Acts).
Administrative Law: Authority delegated to government agencies (e.g., State Boards of Nursing).
Civil Law: Enforces individual rights (e.g., malpractice lawsuits for injuries, like birth trauma).
Criminal Law: Addresses unlawful behavior and prosecution of offenders.
Remember: State legislatures pass practice laws for all licensed professions, including nursing, dentistry, and medicine.
The Nurse Practice Act:
Defines minimum educational qualifications and other licensure requirements.
Outlines the scope of practice for nurses in a specific state (e.g., LPNs starting IVs in Nebraska vs. Texas, depending on training and state law).
State Board of Nursing (Regulatory Body):
Ensures nurses are licensed and adhere to state nursing practice acts.
Administers and enforces these acts.
Has authority to censure (probation, suspension, revocation) licenses for violations of the Nurse Practice Act (e.g., drug problems).
Sets and enforces minimum criteria for nursing education and continuing education credits.
Continuing Education (CE): Requirements vary significantly by state (e.g., Missouri: 0 hours; California: 30 hours every two years, Nevada: 30 hours plus 4 hours bioterrorism & 2 hours cultural competency).
ANCC (American Nurse Credentialing Center): A branch of the ANA, provides a free platform for tracking approved continuing education, useful for certification and audits.
Licensure:
NCLEX-RN: National exam for licensure, conceptualized by the NLN in 1950.
Licensure by Endorsement: Applying for a license in a new state while already licensed in another (e.g., applying for a Nevada license while licensed in Missouri).
Licensure Compact: A coalition of states where a nurse holding a license in one compact state can practice in any other compact state without additional licensure, due to similar standards. The number of compact states is growing, with at least 25 states currently participating.
Legal Risk in Nursing Profession:
Malpractice / Professional Negligence: A professional fails to act as a reasonably prudent professional would have under similar circumstances.
Involves either doing something that should not have been done or failing to do something that should have been done.
Requires the nurse to have specialized knowledge and skills, and the patient's injury must be a direct result of the nurse's failure to apply these (e.g., a student nurse is usually covered under the supervising RN's license).
Delegation:
The RN is the only person who can delegate.
The delegating RN is ultimately responsible for the delegated tasks.
Important Caveat: Clear your mind of real-world practices; delegation on boards/for basic knowledge focuses on RN delegation.
The Five Rights of Delegation:
Right Task: Appropriate for the specific care situation (e.g., not sending a nurse aide to therapeutically communicate with a grieving patient).
Right Circumstances: Appropriate for the patient's health status, care complexity, and required care delivery (e.g., patient with multiple IV pumps and oxygen).
Right Person: The delegatee must be competent and trained for the task (e.g., ensuring a new grad has been oriented).
Right Direction and Communication: Clear, specific instructions including when, where, how, and why (e.g., detailed wound care instructions).
Right Supervision or Evaluation: The delegator must be able to supervise and evaluate the task's performance.
Delegator vs. Delegatee Responsibilities:
Delegator (RN): Ensures delegatee is competent, trained, and that the task aligns with policy. Accountable for the task's completion and adequate follow-up.
Delegatee (LPN, UAP, or another RN): Responsible for carrying out delegated tasks and for informing the delegator if untrained or uncomfortable with a task.
Informed Consent:
Voluntary: Patient's decision must be without coercion.
Capacity/Competence: Patient must understand the information or have an authorized person make decisions for them (e.g., mental health issues).
Sufficient Information: Patient must receive enough information to make a decision, including risks.
Provider's Responsibility: The healthcare provider is responsible for explaining the treatment, risks, and answering questions. They must sign the consent form.
Nurse's Role: The nurse may witness the patient's signature but is not responsible for explaining the treatment or answering questions about the procedure. If the patient has questions, the provider must return.
Ethical Foundations of Nursing Practice
Types of Ethics:
Metaethics: Focuses on universal truths, how ethical principles develop (e.g., "treat others the way you want to be treated").
Normative Ethics: Focuses on moral standards that regulate behavior (e.g., wearing masks during COVID for public safety).
Applied Ethics: Focuses on specific difficult issues (e.g., right to life, capital punishment, abortion, health disparities).
Basic Ethical Concepts:
Values: Personal beliefs about what is important.
Morals: Principles of right and wrong, often based on personal experiences or religious beliefs.
Ethics: Systematic study of moral principles and actions.
Bioethics: Ethical issues related to healthcare (e.g., blood transfusions, end-of-life decisions).
Code of Ethics: A non-negotiable code of conduct for ethical professional nursing practice (e.g., ANA Code of Ethics).
Moral Distress: Response when nurses face ethical dilemmas and institutional constraints.
Ethical Theories:
Deontology: An act is moral if its motives and intentions are good, regardless of the outcome (e.g., performing CPR on someone initially unknown to have a DNR).
Utilitarianism: Moral rightness is based on the consequence; doing the "greatest good for the greatest number" (e.g., masking during COVID to protect vulnerable populations).
Virtue Ethics: Emphasizes the character of the decision-maker, including training and natural tendencies.
Principalism: Uses key ethical principles to address ethical situations.
Key Ethical Principles (from Principalism theory, Chapter 7):
Autonomy: Respect for the individual's right to make their own decisions.
Beneficence: Doing good, advocating for the patient's well-being (unless it causes harm).
Nonmaleficence: "Do no harm."
Justice: Being fair, providing impartial and equitable care according to needs, aligning with social justice.
Fidelity: Loyalty and truthfulness, keeping promises.
Veracity: Telling the truth, honesty.
ANA Documents and Scope of Practice
ANA Code of Ethics for Nurses (9 Provisions):
A social contract that shapes professional self-regulation.
Outlines safe practice based on acting ethically and with compassion.
Commitment to the patient, promoting and advocating for the patient and their family.
Supports autonomy and goal-setting.
Emphasizes professional performance behaviors.
Non-negotiable obligation for every nurse.
Core idea: Acting on what is right and providing client-centered care.
ANA Scope and Standards of Practice:
Provides overall guidance for skills and responsibilities for all nurses, regardless of state.
Assigns roles: caring, basic needs, interdisciplinary collaboration, advocacy for equal treatment and social justice, promoting human rights, leadership, education, and research.
Emphasizes participation in research and staying current with best practice.
ANA Social Policy Statement:
Identifies the current knowledge base for nurses (e.g., baccalaureate degree nurses).
Indicates specializations and advanced practice roles (e.g., Nurse Practitioner).
Includes the Code of Ethics for Nurses.
State-Specific Standards & Compact States:
Nurses must meet both the overarching ANA standards and their individual state's nursing practice act.
Compact states allow licensure portability due to aligned practice standards. There are many compact states (e.g., highlighted blue on a map, with some in process indicated green), but some states like California are not part of the compact, though they may have specific legislative mandates like nurse-patient ratios.
It is crucial for nurses to know the laws and expected competencies for every state in which they are licensed.
Overall Takeaway: Be aware of your responsibilities as a nurse at both the national (ANA) and state levels. Always strive for competence, best practice, and ethical patient advocacy.