SH

Ethical and legal concerns

Standards of Practice and QSEN

  • The American Nurses Association (ANA) publishes standards of care to ensure the safety of the public. These standards are described as duties all registered nurses must follow regardless of specialty population. A competency is linked to the standard. When the nurse maintains these standards and competencies, safe nursing care is ensured.
  • The ANA standards of practice consists of:
    • 1 assessment
    • 2 diagnosis
    • 3 outcomes identification
    • 4 planning
    • 5 implementation
    • 6 evaluation
    • 7 ethics
    • 8 advocacy
    • 9 respect and equitable practice
    • 10 communication
    • 11 collaboration
    • 12 leadership
    • 13 education
    • 14 scholarly inquiry
    • 15 quality of practice
    • 16 professional practice evaluation
    • 17 resource stewardship
    • 18 environmental health
  • Every state also has a nurse practice act describing the laws governing nursing practice. Every state board of nursing enforces these laws.
  • A registered nurse uses knowledge, critical thinking, and skills to interpret these laws and follow standards of care.
  • In 2015, WHO developed a framework to improve quality of maternity care. The framework addresses quality maternity care through two dimensions: quality provisions of care and experience of care.
    • Provisions of care include: ext{evidence based practice}, ext{efficient information and referral systems}.
    • Experience of care includes: ext{effective communication}, ext{respect, dignity, and emotional support}.
  • Barriers to quality maternity care hypothesized by the framework include:
    • Non-implementation of evidence-based care
    • Fear of litigation resulting in over-medicalization of maternity care
    • Lack of systems to evaluate and monitor quality using quantitative indicators
    • Lack of inclusion of maternal perceptions of care
  • The Association of Women's Health Obstetrics and Neonatal Nurses (AWHONN) also sets standards of care. Staffing in maternal–newborn care units is crucial for safety and quality. AWHONN has published evidence showing that inadequate staffing leads to negative patient outcomes. To determine staffing needs, the clinical situation and patient acuity must be assessed.
  • AWHONN’s standards for professional registered nurse staffing for perinatal units are listed in Table 1-3 (referenced in the transcript).

Risk Management and Perinatal Safety

  • Risk, per Healthcare Risk Management Company, is defined as anything that can result in an unexpected outcome or loss. Risk management involves identifying risk factors by analyzing processes and procedures and implementing programs to address risk and prevent patient harm.
  • Some risk-management projects arise from negative patient outcomes. Risk-management nurses work with administration and health-care providers to determine potential risks for patients and work with the legal team to identify breaches and standards of care.
  • Risk management involves disclosing errors or anticipated outcomes to the patient in language a layperson can understand, along with an apology and plan for correction. Such disclosure allows the patient and family to ask questions, the nurse and hospital to express apologies, and the patient to have closure.
  • In perinatal care, a treatment or assessment by a nurse that is not performed is called an error of omission.
  • Hafta et al. studied perinatal care in Ethiopia and found that, in both developed and developing countries, labor and delivery nurses admitted the following care elements most often as omissions:
    • 1 Physical exam
    • 2 Ongoing and timely monitoring of patient status
    • 3 Intake and output measures
    • 4 Response to rapidly changing conditions or deterioration
    • 5 Reassuring the mother
    • 6 Documentation
    • 7 Timely nurse-to-patient communication
    • 8 Completing review of history
    • 9 General comfort care based on patient needs
    • 10 Repositioning when patient needs to
  • The study reported 74.6\% of nurses studied missed at least one nursing element of care, with omissions primarily due to: lack of labor resources, inadequate staffing, and inexperienced staff; and also factors like teamwork, resources, medication/equipment availability, and communication.
  • Teamwork and communication are extremely important for patient safety and risk management.
  • Risk-management programs investigate why errors occur. The most common errors in medicine relate to communication issues. In one study, obstetric nurses interrupted during preparation, management, and documentation had more medical errors. An interruption of care leads to interruption of work and unpredictable results.
  • Another major cause of nurse error is communication issues. Communication errors account for 72\% of perinatal deaths.
  • Zabari and Southern found that obstetric nurses and health-care providers report fewer errors than other specialties, possibly because birth is not perceived as a medical procedure. Consequently, families may have expectations of perfect births, leading nurses to feel shame and guilt when errors occur and to underreport them. This underreporting hinders risk-management opportunities and interventions.
  • The nurse plays a critical role in identifying risks and implementing changes to reduce risks.

QSEN: Quality and Safety Education for Nurses

  • The QSEN project started in 2005 to address improvements needed in health-care quality and safety.
  • Six quality and safety competencies with knowledge, skills, and attitude statements were developed:
    • 1 Patient-centered care
    • 2 Teamwork and collaboration
    • 3 Evidence-based practice
    • 4 Quality improvement
    • 5 Safety
    • 6 Informatics
  • The QSEN competencies were designed to shift nursing from focusing on tasks to focusing on knowledge, skills, and attitudes (KSA concepts) for quality and safety.
  • Although developed for nursing education, these competencies have been used by nursing organizations for continuing education and by hospital administration to promote continual quality and safety of care.
  • Nurses are integral to utilizing evidence-based care to ensure effective, safe, and high-quality nursing care.

Legal and Ethical Issues in Maternal–Newborn Nursing

Legal issues in maternity care

  • Obstetrics and gynecology are specialties with high rates of litigation. Possible reasons for malpractice suits in intrapartum patients include:
    • Childbirth is an intense emotional experience subject to family expectations
    • Parents may be well-informed consumers of health care
    • Obstetric care is high-pressure and rapidly changing where accidents, errors, and judgments occur
    • Nurses are given more accountability and autonomy
    • Nurses are held to a standard of care for OB patients and must exercise ordinary prudent judgment
    • If the health-care team does not meet the standard of care and a negative outcome occurs, families may pursue legal action
  • Common error types in OB malpractice include:
    • Improper administration of medications such as MgSO_4, Oxytocin, Insulin, and Heparin
    • Failure to assess and monitor for side effects of medications or interventions
    • Improper use of equipment or lack of available equipment
    • Poor communication and/or collaboration
    • Failure to act as patient advocate and initiate the chain of command
    • Failure to follow provider orders
    • Failure to verify informed consent
  • Economic and policy factors have led to the closure of many nurse-midwife and obstetric practices in parts of the US due to financial constraints, low delivery numbers, and liability concerns, creating “birthing deserts.”
  • Nurses must follow their nurse practice acts and hospital policies and should be proactive in reporting unsafe working conditions (e.g., too few nurses, high patient complexity, equipment failures) to improve quality and safety.

Ethical issues in maternal–newborn nursing

  • Surrogacy: Surrogates carry and birth a baby for another person or couple. Some surrogates share DNA with one or both parents, or with neither. Ethical concerns include whether selling reproductive abilities is acceptable; some countries ban surrogacy, and U.S. states regulate it differently. The approximate cost in the U.S. is 100{,}000, including health care, legal, and sometimes travel fees. Insurance rarely covers these fees, raising equity concerns about who can access surrogacy.
  • Female genital mutilation/cutting (FGM/C): Removal of all or part of the external female genitalia for nonmedical reasons. More than 2\times 10^{5} girls and women in Africa, the Middle East, and Asia have been cut. Some view FGM/C as cultural or religious, while others see it as a human rights violation. Nurses should provide support and education to patients and families.
  • Informed consent and autonomy in maternity care: Kingsma notes that touching a patient’s ear or knee without consent is less consequential than touching the vulva or vagina without consent, which can cause devastating emotional trauma. Given that approximately 30\% of persons AFAB in the U.S. have experienced sexual assault, nurses and other providers must be gatekeepers of informed consent, particularly during labor and physical exams.
  • Ethical guidelines in perinatal nursing and research: Before beginning research, investigators must obtain approval from an Institutional Review Board (IRB). The board must consider pregnant persons as scientifically complex and consider both the pregnant person and the fetus when recruiting participants. Historically, persons AFAB were excluded from medical research, but the NIH now requires inclusion of women in NIH-funded research unless inappropriate. The example of thalidomide indicates how lack of research can have real consequences; extensive research might have prevented certain birth defects. Informed consent must thoroughly explain benefits and risks. Research involving fetus may require paternal consent as well.
    • Maternal consent: consent from the pregnant person, provided when the information shows a potential direct benefit to the pregnant person and the fetus, or when there is no direct benefit but minimal risk to the fetus and the purpose is to develop important biomedical knowledge that cannot be obtained otherwise.
    • Paternal consent: consent from both the pregnant person and the partner; however, the partner does not have to give consent if unavailable, incompetent, incapacitated, or if the pregnancy resulted from rape or incest.
    • Information presented to participants must show that the research has a chance of direct benefit solely to the fetus when relevant.
  • Embryonic tissue and stem cell research:
    • Embryonic stem cells are undifferentiated cells that can renew themselves and develop into many different cell types; they can differentiate into all cell types except placenta cells.
    • History includes early polio vaccine development from fetal tissue in 1954, and broader investigations into HIV infection, immune disorders, diabetes, transplantation rejection, cancer, and more.
    • Use of fetal tissue has been controversial due to tissue donation from terminated pregnancies.
    • In 02/2019, the government placed restrictions on NIH funding for research using fetal tissue, with some restrictions lifted in 2021. The use of stem cells in research remains ethically and morally debated.
  • Maternal–fetal conflict:
    • Two patients must be considered: maternal interests and fetal interests are often incompatible, leading to maternal–fetal conflict. Often the mother is treated as the secondary patient, while the fetus is treated as the main priority. The idea of maternal self-sacrifice is common but not universal.
    • Conflicts can arise when the pregnant person refuses treatment; when a provider performs treatment for fetal distress without consent (e.g., emergency cesarean), it can lead to assault charges.
    • The American Academy of Pediatrics (AAP) Committee on Bioethics suggests three circumstances to question a maternal decision: (1) the fetus is susceptible to irrevocable harm if treatment is not administered; (2) the treatment is indicated and likely to work; (3) there is minimal risk to the pregnant person.
  • Abortion:
    • Any pregnancy loss before 20\text{ weeks} gestation is considered an abortion. The topic is complex and controversial in women's health care.
    • History of abortion laws in the United States (as summarized in the transcript):
    • In the 1800s, abortions were legal until the time of quickening (~20\text{ weeks}).
    • Early 1820s: laws designed to protect women from poison sold at apothecaries, not to ban abortions.
    • In the nineteen hundreds, physicians influenced states to limit abortion; abortion became illegal in 1910.
    • In the 1960s, abortion was discussed more openly; in 1973, Roe v. Wade legalized abortion.
    • In 1977, political and anti-abortion groups pressured laws restricting federal funds for abortion care.
    • In 2022, Roe v. Wade was overturned by Dobbs v. Jackson Women's Health Organization.
    • Globally, roughly half of all pregnancies in 2022 were unplanned (about 121\times 10^{6} pregnancies).
    • Reproductive care remains limited for many patients; abortion is a polarizing issue globally.
    • The discussion centers on when life begins. The job of an obstetrician-gynecologist (OBGYN) nurse is to support the patient without allowing personal beliefs or moral judgments to influence quality of care. The American College of Obstetricians and Gynecologists (ACOG) states that the best health care is free from political interference.

Connections and practical implications

  • Across standards, risk management, QSEN, and ethics, the consistent themes are patient safety, nonmaleficence, autonomy, informed consent, and transparent communication.
  • Nurses play a central role in identifying risks, advocating for patients, ensuring evidence-based practices are implemented, and avoiding unnecessary interventions driven by fear of litigation.
  • Legal and ethical issues in maternal–newborn care require balancing maternal rights with fetal considerations, while recognizing societal and cultural diversity in beliefs about reproduction, surrogacy, FGM/C, and abortion.
  • Research ethics emphasize inclusion of pregnant persons in biomedical research to improve perinatal care while protecting both the patient and the fetus.
  • Practical implications include advocating for adequate staffing, thorough documentation, clear patient communication, and proactive risk reduction strategies to improve outcomes in maternity care.