Ethics/Legal

Nursing Care Delivery Models

• Purpose: nursing care delivery models are frameworks for organizing care to help patients achieve desirable outcomes. We’ll cover four common models (there are more, but these are the focus):
• Team Nursing
  • Hospital-wide and very common in clinicals.
  • RN acts as team leader (think quarterback): communicates plan, directs team, and leads care.
  • Team includes other RNs, LPNs, and nursing assistants/unlicensed assistive personnel (UAPs).
  • Key skills: leadership, clear communication, collaboration; outcomes depend on how well the team functions.
• Primary Nursing
  • One RN assumes responsibility for a patient from admission to discharge.
  • Not as common today due to higher cost: paying only RNs is more expensive than mixed staffing.
  • If the primary RN isn’t present, a detailed care plan is left for others to follow.
• Patient- and Family-Centered Care
  • Focuses on partnership with patient and family; patient/family are involved in decisions.
  • RN remains the leader of care; nurses perform assessments, plan care, and evaluate outcomes.
  • Bedside shift reports promote transparency and input from patient/family (they can voice preferences and input).
• Case Management
  • Not direct bedside care; coordinates and links services across all levels of care.
  • Follows patients from admission to discharge, arranging resources and services to prevent gaps (e.g., ED to rehab, home oxygen delivery).
• Why these models matter
  • Organizational structure affects safety, efficiency, communication, and patient outcomes.
  • Effective care delivery requires recognizing patient needs, generating solutions, clinical decision-making, delegation, organization, and outcome evaluation.

Clinical Judgment and Care Coordination

• Clinical Judgment
  • The first clear coordination skill; develops with experience and nursing process knowledge.
  • The nursing process is iterative: assess, diagnose, plan, implement, evaluate, adjust as needed.
• Initial Patient Contact
  • Establish a therapeutic relationship from the first interaction.
  • Seven-second rule: people form first impressions quickly; trust is essential to care quality.
  • AIDET communication framework for introductions and expectations:
  • Acknowledge
  • Introduce
  • Duration
  • Explanation
  • Thank you
• Patient Assessment
  • Use open-ended questions to elicit information about disease processes and daily impact.
  • Build the patient picture by comparing what you expect with what the patient presents; not all patients present the same way even with the same diagnosis.
  • Seek help from experienced nurses when needed.
• Priority Setting (Care Prioritization)
  • After building a complete picture, set priorities (high, intermediate, low).
  • High priority criteria (activate immediately): ABCs (Airway, Breathing, Circulation) + BL (critical life threats, bleeding, etc.). Treat these stat.
  • Intermediate priorities include: mental status changes, untreated medical issues, acute pain, elimination problems, abnormal labs, and risk factors (e.g., fall risk).
  • Low priority tasks are less urgent but still important.
  • Maslow’s hierarchy can guide prioritization: satisfy basic needs before higher-level needs when appropriate, but always prioritize life-threatening issues first.
  • Example: a patient stating they feel they might die should prompt urgent assessment.
• Organizing Your Care
  • Being organized means: preparing supplies, planning care, clustering tasks, and grouping activities to maximize efficiency.
  • Cluster care: complete several care activities in one room visit (e.g., med administration plus assessment and teaching) to reduce repeated room entries.
  • Always keep the patient as the top priority; contingency plans are normal as plans change with patient status.
• Time Management
  • Shifts are long (often 12 hours) with multiple patients; time per patient is limited.
  • Create and adjust to flexible checklists; lists help focus, but be adaptable as priorities shift.
• Delegation and Team Roles
  • Delegation transfers responsibility for tasks to another qualified person in a given setting.
  • Follow the five rights of delegation: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision/Evaluation.
  • Competence matters: use skills checkoffs to prove ability; delegate only tasks within the delegatee’s scope and demonstrated competence.
  • Accountability remains with the RN; the task is delegated, but outcomes and patient safety still trace back to the RN.
  • Examples of delegation: UAPs handle vital signs, basic hygiene, and routine tasks; LPNs may perform certain med tech tasks; RNs retain assessment and clinical judgment duties.
• Evaluation
  • Continuous process: after implementing care, evaluate whether outcomes are met; if not, modify the plan.
  • Example: administer oxygen, then assess whether oxygen saturation improves; adjust interventions as needed.
• Effective Leadership and Team Work
  • Leaders must recognize limitations and ask for help when needed; know when to escalate or consult experienced colleagues.
  • Avoid arrogance; asking for help enhances safety and learning.

Organizational Skills, Time Management, and Delegation Details

• Effectiveness vs Efficiency
  • Effective: doing the right things; efficient: doing things the right way.
  • Aim to be both: avoid spending excessive time on one task (e.g., a two-hour bed bath) if it isn’t efficient; cluster tasks to minimize interruptions and patient distress.
• Preparation and Proactivity
  • Be prepared before entering a patient’s room: gather supplies, anticipate needs, and prep the patient for procedures.
  • Coordinate with colleagues if help is needed and plan ahead.
• Fluidity of Plans
  • Plans can change; be flexible and adapt to the patient’s evolving condition and other urgent needs (e.g., a chest X-ray takes priority over continuing a non-urgent med pass).
• Keeping the Patient as Priority
  • The patient’s well-being and safety must remain the central focus of all decisions.
• Resources and Team Utilization
  • Resources include supplies and team members; the quarterback (RN) leads, but rely on the team to achieve goals.
  • Respect your team members; recognize that each role is essential to patient care.
• Time Management Strategies
  • Use checklists, prioritize tasks, and batch care when appropriate.
  • Accept that priorities may shift; maintain clear communication about changes in plan.
• Handling Delegation Challenges
  • If a delegated task is performed incorrectly, provide feedback privately and focus on one issue at a time.
  • Consider competence and scope; if someone isn’t competent for a task, do not delegate it.
  • Ensure follow-up, evaluation, and constructive teaching when needed.
• When and What to Delegate
  • Typical delegated tasks: vitals by UAP; med administration by RN; some dressing changes or basic procedures by LPNs (depending on licensure and state rules).
  • Never delegate clinical judgment, comprehensive assessments, or tasks beyond a person’s scope or competence.
• Floating and Staffing Challenges
  • Floating to different units is common; verify assignment scope and capabilities; ask questions if unclear.
  • Adequate staffing is required for safe care; if staffing is insufficient, advocate for appropriate patient placement or escalation.
• Safety and Abandonment
  • Do not abandon a patient during handoff or after initiating care; ensure proper handoff and continue care until transfer.
• Student Liability
  • Nursing students are liable for actions performed under supervision; do not perform tasks beyond training or unauthorised by the instructor.
  • If you are in a role (e.g., nursing assistant) with a different scope, adhere to that scope and seek supervision as required.

Ethics and Professional Codes

• Overview
  • Ethics provides a framework for making decisions when faced with morally charged situations; it is not the same as law, but often interacts with legal obligations.
• Key Ethical Principles (as discussed)
  • Autonomy: respect patients' right to make their own decisions about their care.
  • Beneficence: act in the best interest of patients; do good.
  • Nonmaleficence: do no harm; weigh benefits vs harms of actions.
  • Justice: fairness in distribution of resources and access to care.
  • Fidelity/Accountability: keep promises and be answerable for actions.
  • Confidentiality: protect patient privacy and PHI; distinguish privacy (wider concept) from confidentiality (keeping disclosed information confidential).
• Code of Ethics (ANA)
  • A guiding set of expected behaviors and standards for nurses.
  • Key components highlighted: advocacy, responsibility, accountability, confidentiality.
  • Advocacy: defend and support patients’ rights and well-being; challenge decisions that may harm patients.
  • Responsibility: fulfill professional obligations and maintain competency; follow through with duties.
  • Accountability: answer for actions and explain decisions; be able to justify actions.
  • Confidentiality: safeguard patient information; avoid inappropriate disclosures (including on social media).
• Ethics vs Law
  • Ethics guides behavior and helps navigate morally ambiguous situations; legality defines what is permissible and is enforceable by law.

Legal and Regulatory Framework

• Nurse Practice Act (NPA) and State Boards of Nursing
  • Establish scope of practice for RN, LPN, and CNA; define what each role can and cannot do.
  • Create state nursing boards responsible for licensure and discipline (suspension, revocation, investigations).
  • Licensure is a privilege, not a right; failure to comply with the NPA can lead to loss of license.
  • Nurse Licensure Compact (NLC): allows a nurse to practice in multiple compact states with one home state license; about 39 states participate; others require separate licenses.
  • Boards investigate complaints (within their own processes, not civil court); facts are public in some formats (e.g., disciplinary actions announced by boards).
• Standards of Care and Liability
  • Standards of care describe the minimum acceptable care to ensure patient safety and quality; informed by state law, accrediting bodies, professional organizations (e.g., ANA), and evidence-based guidelines.
  • Standard of proof in negligence/malpractice: duty of care, breach of duty, causation, damages. If harm results from failure to meet standard, liability may arise.
  • Negligence vs Malpractice
  • Negligence: general duty breached, leading to harm.
  • Malpractice: professional negligence; specific to healthcare professionals and professional standards.
• Documentation and Duty to Act
  • Proper documentation is essential to defend decisions and actions; documentation should reflect what was done and why.
  • Use safety checks (e.g., patient/medication verification via scanning) to prevent errors.
• Samaritan Law
  • Encourages bystander assistance during emergencies; provides limited immunity for first aid performed within scope; must provide appropriate care and not exceed scope; must stay with the patient until transfer of care occurs.
• Public Health and HIPAA (Privacy and Confidentiality)
  • HIPAA protects patient privacy and PHI; patients have rights to consent, access, amend, and control disclosures of PHI; information must be accessible only to those with a need to know.
  • Privacy vs Confidentiality:
  • Privacy: protection of information from disclosure.
  • Confidentiality: keep information disclosed in care confidential within safe settings.
  • HIPAA Exceptions: public health reporting (TB, HIV, other reportable diseases) when non-disclosure risks public health; immunization reporting; CDC/OSHA guidelines influence health policies.
  • Social media cautions: never post PHI; do not discuss patients in cafeterias/elevators; avoid adding patients on social networks; these practices breach confidentiality and can lead to legal/disciplinary action.
• Patient Self-Determination Act and Advance Directives
  • Institutions must provide written information about patients’ rights to make decisions, including refusal of treatment and advance directives.
  • Living wills and durable power of attorney for health care are common advanced directives; at minimum, directives must include code status and a durable power of attorney; code status is an order (physician/provider) that must be documented.
  • The durable power of attorney for health care designates someone to make decisions if the patient becomes incapacitated; it is valid only when the patient cannot participate in decisions.
  • Documentation and witness requirements are essential; if a patient cannot consent (unconscious, under heavy sedation), those decisions may be staged or deferred to legal surrogates.
• Informed Consent
  • Informed consent requires disclosure of risks, benefits, alternatives, and consequences of refusing treatment; the patient or surrogate must be competent to consent.
  • The provider (usually surgeon) obtains the consent; nurses witness and ensure patient is coherent and understands the information.
  • If language barriers exist, use professional interpreters (not family members) to ensure true understanding.
  • If consent is not obtained, performing procedure could constitute battery; consent must be obtained prior to procedure.
• Organ Donation and Uniform Anatomical Gift Act (UAGA)
  • Establishes organ donation processes; effective 18+ years; patients may designate donation on licenses or via advance directives; UNOS governs organ allocation; priority depends on severity and proximity to organ; there are policies to prevent organ sale (National Organ Transplant Act).
• Omnibus Budget Reconciliation Act (OSRA) and Restraints
  • OSRA addresses care in long-term care facilities and prohibits unnecessary restraints; emphasizes patient rights to quality of life and safe environment.
  • Restraints: defined as anything that restricts movement (physical, mechanical, or chemical); use only after less restrictive measures have failed; require orders and ongoing monitoring; include ROM and safety checks; restraints are last resort due to safety risks.
• Abuse and Neglect Reporting
  • Nurses are mandatory reporters of abuse/neglect of children and vulnerable adults; failure to report can lead to legal consequences; hotlines exist for reporting (state health department and CPS).

Ethical and Legal Intersections in Practice

• Decision-Making Frameworks
  • Clinicians must apply critical thinking, clinical judgment, ethics, and legal considerations when making decisions.
  • When faced with ethical dilemmas (e.g., end-of-life decisions or quality of life considerations), weigh autonomy, beneficence, nonmaleficence, justice, and social implications.
• End-of-Life and Quality of Life Considerations
  • Ensure patient and family goals align with care decisions; pain management at end of life is a central ethical concern; assess burdens vs benefits of treatments (e.g., aggressive interventions in terminal illness).
  • Respect patient wishes regarding end-of-life care, including refusal of treatment via advance directives.
• Professional Boundaries and Social Media
  • Maintain professional boundaries; avoid personal connections with patients on social media; protect patient privacy and confidentiality at all times.
• Practical Applications for Exam Prep
  • Understand and memorize the five rights of delegation; be prepared to justify delegation decisions based on scope and competence.
  • Be able to articulate how to perform a bedside shift report and why it supports patient-centered care.
  • Be ready to distinguish between autonomy, beneficence, nonmaleficence, justice, fidelity, and confidentiality, with examples.
• Quick Reference Mnemonics and Concepts
  • AIDET for patient communication: Acknowledge, Introduce, Duration, Explanation, Thank you.
  • ABCs + BL for high-priority assessment/decisions: Airway, Breathing, Circulation (plus Life-threatening Bleeding or similar urgent concerns).
  • Five Rights of Delegation: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision and Evaluation.
  • Maslow’s Hierarchy as a heuristic for prioritization in certain contexts.
• Important Legal References (where to look in practice)
  • Nurse Practice Act (NPA): state-specific scope of practice; licensing and discipline via the state Board of Nursing.
  • Nurse Licensure Compact (NLC): enables practice across participating states with one license.
  • Standards of Care vs Standard of Proof: the standard of care defines expected practice; standard of proof governs negligence/malpractice claims.
  • HIPAA: privacy and PHI protections; confidentiality after disclosure; privacy vs confidentiality nuances; exceptions for public health and emergency reporting.
  • Public Health Reporting: reportable diseases (e.g., TB, HIV); vaccination guidelines; CDC/OSHA guidelines influence practice.
  • Samaritan Law: limited immunity for bystander first aid; must stay and provide care within scope; do not exceed scope.
  • OSRA and Restraint Regulations: rights of residents in long-term care; use of restraints strictly controlled and monitored.
• Final Note for Exam Readiness
  • You will be tested on how to differentiate care models, apply clinical judgment, perform prioritization, execute delegation correctly, and navigate ethical/legal issues.
  • Expect scenarios asking you to identify appropriate actions under HIPAA, consent, advance directives, and the nurse practice act; expect to justify decisions with ethical principles and safety best practices.