Nursing Ethical Dilemmas: Delegation and Prioritization of Client Care, Exams of Nursing

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Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers define terminology commonly used in discussions about ethical issues - correct answer advance directive- a written statement of a persons wishes about how he or she would like health care decisions to be made if he or she ever loses the ability to make such decisions independently bioethical issues- subjects that raise concerns of right and wrong in matters involving human life (eg euthanasia, abortion) bioethics- ethics concerning life durable power of attorney for health care- a document that allows a person to name someone else to make medical decisions for him or her if he or she is unable to do so. this spokesperson's authority begins only when the patient is incompetent to make those decisions ethics- rules or principles that determine which human actions are right or wrong ethical dilemma- 1. a situation involving competing rules or principles that appear to have no satisfactory solution Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers 2. a choice between two or more equally undesirable alternatives living will- a document that allows a person to state in advance that life- sustaining treatment is not to be administered if the person later is terminally ill and incompetent moral/ethical principles- fundamental values or assumptions about the way individuals should be treated and cared for moral courage- the willingness to do what is right despite the fear of consequences moral distress- feeling of powerlessness to do what is right and ethical moral reasoning- a process of considering and selecting approaches to resolve ethical issues moral uncertainty- a situation that exists when the individual is unsure which moral principles or values apply in a given situation Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers d. Fidelity - the duty to be faithful to commitments. Loyalty. Follow through. Includes confidentiality. i. The nurse keeps confidential information confidential and follows through on commitments. ii. "I promise ... and I always keep my promises." e. Justice -the duty to treat all patients fairly without regard to age, socioeconomic status, or other variables. i. The nurse understands and acknowledges allocation of scarce healthcare resources but also meets each patient's needs consistently regardless of variables. ii. "I will treat you fairly." f. Veracity - the duty to tell the truth. i. Nurses must be truthful to their patients. ii. " I will tell you the truth." discuss resources available to nurses when dealing with ethical issues - correct answer 1. Resources available to help nurses resolve ethical dilemmas a. ANA Code of Ethics for Nurses Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers b. Patient's Bill of rights - Patient Care Partnership c. Hospital's Ethics Committee discuss current ethical issues nurses may face in healthcare - correct answer 1. Ethical issues confronting nurses a. Abortion b. Euthanasia --Physician-Assisted Suicide c. Futile Care- medical intervention without reasonable hope of benefit to the patient (ICU, advance directive?) d. Transplantation- who should receive? how are donors solicited? illegal to buy organs i. Deceased patients ii. Fetal tissue- e. In vitro fertilization Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers f. Genetics and genomics g. Allocation of scarce resources Common legal terms - correct answer advance directive- a document made by a competent individual to establish desired health care for the future or to give someone else the right to make health care decisions if the individual becomes incompetent, examples include living wills and medical powers of attorney defamation- a civil wrong in which an individuals reputation in the community, including the professional community, has been damaged defendant- the person who is being accused of wrongdoing, the person then must defend themselves against the charges, this is the nurse or other health care provider deposition- out of court oral testimony given under oath before a court reporter, the purpose is to enable attorneys to ask questions and receive answers related to the case Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers 2. Statutory law- statutes created by legislature can be federal, state, or local. Most common type of law affecting nurses-Nurse Practice Act 3. Administrative law- rules and regulations passed by administrative agencies-BON (federal laws affecting nursing include: HIPAA, americans w/ disablities act, mental health parity act, national organ transplant act) Nurse Practice Acts- -each state has one, -both statues and administrative rules, -qualifications, regulations and monitoring of RNs 1. Criminal law- prosecution and punishment for a crime 2. Civil law - Rights between individuals 3. Common law or Case law- decisions made by judges in court cases explore differences between criminal law and civil law as they pertain to nursing (per ati) - correct answer Criminal law- is a subsection of public Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers law and relates to the relationship of an individual with the government. violations of criminal law can be categorized as: *a felony: (a serious crime, such as a homicide) *or a misdemeanor: (a less serious crime such as petty theft) Ex. a nurse who falsifies a record to cover up a serious mistake can be found guilty of breaking a criminal law Civil laws- protect the individual rights of people. one type of civil law that relates to the provision of nursing care is tort law. torts can be classified as unintentional, quasi-intentional, and intentional Unintentional torts: (ACTING or FAILING to act as a REASONABLE and PRUDENT person would, resulting in HARM to a person to whom a DUTY was owed.) *Negligence (is the most common)-practice or misconduct that does not meet expected standards of care and places the client at risk for injury Ex. a nurse who fails to implement safety measures for a client who has been identified as at risk for falls *Malpractice-professional negligence Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers Ex. a nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. Intentional torts: *Assult- the conduct of one person makes another person fearful and apprehensive Ex. threatening to place an NG tube in a client who is refusing to eat *Battery- intentional and wrongful physical contact with a person that involves an injury or offensive contact Ex. restraining a client and administering an injection against his wishes *False imprisonment- a person is confined or restrained against his will Ex. using restraints on a competent client to prevent his leaving the health care facility Quasi-intentional torts: *Defamation- false communication or communication with careless disregard for the truth with the intent to injure an individuals reputation discuss the components of negligence as applied to nursing practice (ati) - correct answer Malpractice (professional negligence) Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers vi. Failure to assess, monitor, and obtain assistance vii. to communicate adequately viii. Failure to report c. Important documentation: i. Patient's condition on admission and discharge ii. Assessment after incident, physical and mental condtion iii. Patient's non-compliance with medical directives iv. Patient complaints or v. Note exactly what the patient says and admits to vi. Discharge instructions d. Who has liability in a claim? i. The nurse-personal liability ii. The supervisor-supervisory liability iii. The institution-institutional liability iv. The student-student liability Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers explain how standards of care and nursing practice acts are used in determining negligence and malpractice - correct answer nurses base practice on established standards of care or legal guidelines for care. these standards of care can be found in the following: *the nurse practice act of each state *published standards of nursing developed by professional organizations- ANA, ACCN, oncology nurses society etc *accrediting bodies (the join commission) *originally mandated quality assurance programs *sentinel event reporting *failure mode and effects analysis *NPSG * health care facilities policies and procedures -Standards of care guide, define and direct the level of care that should be given by practicing nurses. they are also used in malpractice lawsuits to determine if that level was maintained -Nurses should refuse to practice beyond the legal scope of practice and/or outside of their area of competence regardless of the reason -Nurses should us the formal chain of command to verbalize concerns related to assignment in light of current legal scope, job description, and area of competence Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers explore various laws and how they impact the practice of nursing - correct answer good Samaritan laws - which vary from state to state, protect nurses who provide emergency assistance outside of the employment location. the nurse must provide a standard of care that is reasonable and prudent - state laws vary as to when an individual may begin practicing nursing. some states allow graduates of nursing programs to practice under a limited license whereas some states require licensure by passing the NCLEX before working discuss considerations nurses use when participating in the informed consent process - correct answer 1. Informed consent a. Physician explains risk, benefits, and options b. Physician obtains "informed consent." c. Nurse's role is to witness a signature and clarifying questions d. Criteria for informed consent: mentally competent adult, client understands exactly what they are consenting to, they understand the risks, alternatives, and the outcomes, and the consent is written Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers initiation of diagnostic tests, and provision of nutrition by artificial means. nurses role: -provide written info regarding advance directives -document the clients advance directives status -ensure the advance directive is current and reflective of the client's decisions -recognize that the clients choice takes priority when there is a conflict between the client and family, or between the client and provider -informing all members of the healthcare team of the clients advance directives define nurse jurisprudence according to the texas BON - correct answer Jurisprudence is the science or philosophy of law. The Texas Nurse Practice Act and the Texas Board of Nursing Rules and Regulations Relating to Nurse Education, Licensure, and Practice are the laws that govern the practice of nursing practice in Texas. Your nursing practice is directly affected by your ability to make informed decision within the parameters of these laws. You need to know how the rules apply to you, and then apply them in your nursing practice. Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers state the reason new nurses must take and pass the nurse jurisprudence exam to receive their license to practice professional nursing in Texas - correct answer BON staff have heard nurses who were disciplined by the board proclaim "If only i had known and understood about my 'duty to the patient' under the NPA and board rules I would have not gotten into trouble with the BON" identify several topics covered on the nurse jurisprudence exam - correct answer -licensure and regulation -ethics -practice -peer reviews -disciplinary action make and accept assignments -nurses must take into consideration the staff person's: educational preparation, experience, knowledge and physical and emotional ability Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers explore implications for practice from rule 217.11 standards of nursing practice from the Texas Nurse Practice Act - correct answer Rule 217.11 is the foundation for all other standards: " ...maintain a safe environment for clients and others" *this standard supersedes any physician order, facility policy, or administrative directive explore conditions under which the nurse's duty to a patient begins - correct answer You understand the minimum standards of care once you receive your nursing license -Nurses duty to a patient: *begins when there is a relationship established between the nurse and the patient *begins when the nurse has a responsibility for a patient *doesn't begin with a single event (clocking in) *when a nurse knows or should have known that a situation potentially discuss the process of safe harbor - correct answer -Complete quick request first Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers discuss the nurse's role in reporting violations of the Nurse Practice Act - correct answer -First and foremost, take steps to be sure that you or the patient involved are not in harm's way. --- -Report the situation to a supervisor or the nurse's employer immediately. -Then, contact your state BON (or state licensing authority) and file a complaint. If you are unsure whether a nurse has done something that should be reported, contact the state BON for assistance. -A complaint can be filed at any time by anyone who feels that a nurse has provided incompetent, negligent or unsafe care. Examples of cases where a nurse should be reported immediately include: -Appearance of being impaired by drugs or alcohol while working; -Stealing from a patient or client, including medications; -Providing treatment or care that should be provided only by a physician or advanced practice nurse; -Abusing a patient physically, emotionally, verbally or sexually; or -Involvement in criminal conduct. Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers Basically, you should report any nurse whose behavior is unsafe, incompetent, unethical, affected by the use of alcohol, drugs or other chemicals, or affected by a physical or mental condition. Contact your BON with questions regarding confidentiality and how you, the complainant, may be involved in the process. consider professional boundaries and how to prevent one's own practice from crossing the boundary - correct answer BOUNDARIES AND THE CONTINUUM OF PROFESSIONAL NURSING BEHAVIOR The nurse's responsibility is to delineate and maintain boundaries. The nurse should work within the therapeutic relationship. The nurse should examine any boundary crossing, be aware of its potential implications and avoid repeated crossings. Variables such as the care setting, community influences, patient needs and the nature of therapy affect the delineation of boundaries. Actions that overstep established boundaries to meet the needs of the nurse are boundary violations. Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers The nurse should avoid situations where he or she has a personal, professional or business relationship with the patient. Post-termination relationships are complex because the patient may need additional services. It may be difficult to determine when the nurse-patient relationship is completely terminated. Be careful about personal relationships with patients who might continue to need nursing services (such as those with mental health issues or oncology patients). RED FLAG BEHAVIORS Some behavioral indicators can alert nurses to potential boundary issues for which there may be reasonable explanations. However, nurses who display one or more of the following behaviors should examine their patient relationships for possible boundary crossings or violations. Signs of inappropriate behavior can be subtle at first, but early warning signs that should raise a "red flag" can include: Discussing intimate or personal issues with a patient Engaging in behaviors that could reasonably be interpreted as flirting Keeping secrets with a patient or for a patient Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers The NLC laws allow for the nurse to hold only one active license in his or her primary state of residence. Employers should not require the nurse to apply for licensure in a remote state when the nurse has lawfully declared a primary state of residence based on where he or she pays federal income tax, votes and holds a drivers license. A nurse who holds a license issued by a state that is not a member of the NLC has a single-state license that is only valid in that state. While under some levels of disciplinary action, multistate privileges may be removed and the nurse's practice may be restricted to the home state. define the term assignment, delegation, and supervising - correct answer Assigning: Distribution of work for each staff member over a Specific Period Of Time. Delegating: (nurse holds accountability of nursing care)Process of directing another person to perform Specific Nursing Tasks. Supervising: Directing, monitoring, observing, and evaluating The Performance Of Tasks. Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers Accountability during delegation: - correct answer a. Definition - Required to explain actions or justify decisions to someone b. RN is accountable during delegation to: i. Decide delegate ii. Assess patients needs iii. Plan the desired outcome iv. Assess competency of the delegate v. Give clear directions and get acceptance vi. Follow up - is it completed? Give delegate feedback. NCLEX test plan - correct answer -Identify tasks for assignment or delegation based on client needs -Delegate and assign appropriate task based on client's needs to personnel with competency to perform task -Assign and supervise care of client provided by others (e.g., LPN/VN, assistive personnel, other RNs)* -Communicate tasks to be completed and report client concerns immediately Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers -Organize workload to manage time effectively* -Utilize the rights of delegation (e.g., right task, right circumstances, right person, right direction/ communication, right supervision/evaluation) -Evaluate delegated tasks to ensure correct completion of activity -Evaluate ability of staff members to perform assigned tasks considering personnel's allowable tasks/duties, competency and ability to use sound judgment and decision-making -Evaluate effectiveness of staff members' time management skills 5 rights of delegation -RIGHT Task (info from ATI & Texas BON handout) - correct answer RIGHT Task- ATI Info- *identify what tasks are appropriate to delegate for each specific client *a right task is repetitive, requires little supervision, and is relatively noninvasive for the client Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers *provide appropriate staffing and skill mix, identify clear lines of authority and reporting, and provide sufficient equipment and supplies to meet the collective nursing care needs. *provide appropriate prep in management techniques to deliver and delegate care staff nurse- *assess the health status of inidvudual clients, analyze the data and identify client specific goals and nursing care needs *match the complexity of the activity with the UAP competency and with the level of supervision available *provide for appropriate monitoring and guiding for the combo of client, activity, and personnel 5 rights of delegation -RIGHT Person (info from ATI & Texas BON handout) - correct answer RIGHT Person- ATI info- *assess and verify the competency of the health care team member Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers ---the task must be within the team members scope of practice ---the team member must have the necessary competence/training *continually review the performance of the team member and determine care competency *assess team member performance based on standards and, when necessary take steps to remediate a failure to meet standards EX- RIGHT person= delegate a LVN to admin enteral feedings to a client who has a head injury WRONG person= delgate an AP/CNA to admin enteral feedings to a client with a head injury Texas BON info- Nursing service admin- *establish organizational standards consistent with applicable rules and laws which identify educational training requirements and competency measurements of nurses and UAP *incorporate competency standards into institutional policies; assess nurse and UAP performance; perform evals based upon standards; take steps to remedy the failure to meet standards, including reporting nurses who fail to meet standards to BON Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers Staff nurse- *instruct and/or assess, verify, and identify the UAP's competency on an individual and client specific basis *impelment own professional development activities based on assessed needs; assess UAP performance; perform evals of UAP based upon standards, and take steps to remedy the failure to meet standards 5 rights of delegation RIGHT direction & communication- (info from ATI & Texas BON handout) - correct answer RIGHT direction & communication- ATI info- *communicate either in writing or orally -data that needs to be collected -method and timeline for reporting, including when to report concerns/findings -specific tasks that need to be performed; client specific instructions -expected results, timelines, and expectations for follow-up communication Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers -evaluate client care tasks and identify needs for quality improvement activities and/or additional resources Ex.- RIGHT supervision= delegate the ambulation of a client to an AP/CNA. observe the AP to ensure safe ambulation of the client, and provide positive feedback to the AP after the completion of the task WRONG supervision= delegate the ambulation of a client to an AP without supervision to determine the need for intervention and failing to provide feedback to the AP Texas BON info- Nursing service admin- *assure adequate human resources, including sufficient time, to provide for sufficient supervision to assure that nursing care is adequate and meet the needs of the client *identify the licensed nurses responsible to provide supervision by position, title, role delineation *evaluate outcomes of client community and use info to develop quality assurance and to contribute to risk management plans Staff nurse- Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers *supervise performance of specific nursing activities or assign supervision to other licensed nurses *provide directions and clear explanations of how the activity is to be performed: -monitor performance -obtain and provide feedback -intervene if necessary -ensure proper documentation *evaluate the entire delegation process: -evaluate the client, and -evaluate the performance of the activity compare key components of the RN and LVN scopes of practice & differentiate between the scope of practice for an RN and for an LVN according to the Texas BON - correct answer LVN (*directed practice, cannot practice autonomously in acute care settings like hospitals):! Predictable! health care needs of clients within structured healthcare settings who are experiencing common health care problems with "predictable" outcomes Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers 1-Focused assessments 2-Can participate in planning and modify a nursing care plan 3-Works within scope of practice 4-Implement teaching plan for common health probs 5-LVN cant delegate 6-Assists in evaluating responses 7-Problem-solving approach to analyze clinical data & literature 8-Client advocate to maintain a safe environment 9-behaviors that promote positive outcomes RN (independent practice within the scope of their license): Determine the "predictable or unpredictable" health status and health needs of clients (individuals and families) through "interpretation" of health data and preventive health practice in collaboration with clients and interdisciplinary health care team members. 1-Comprehensive assessments 2-Formulates a nursing care plan 3- Works within scope of practice 4-Develops the teaching plan Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers 5. If "No," Can the UAP be adequately identified? -If "No," Do not delegate 6. If "Yes," Has the RN either instructed the UAP or verified the UAP's competency? -If "No," Provide instruction or verify competency 7. If "Yes," If the delegation continues over time, is the RN able to periodically evaluate the delegation? -If "No," Do not delegate 8. If "Yes," Is there adequate RN supervision of the UAP based on: the stability of the client's status; the UAP's competency; the nature of the delegated task; the proximity and availability of the RN to the UAP -If "No," Do not delegate 9. If "Yes," May consider task for delegation -Tasks Commonly Delegated § 224.8 (a) -Discretionary Tasks § 224.8 (b) Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers -Tasks Prohibited from Delegation § 224.8 (c) -Tasks Commonly Delegated § 224.8 (a) - correct answer (a) 1. non-invasive and non-sterile treatments 2. the collecting, reporting, and documentation of data including but not limited to: -vital signs, height, weight, I/O, capillary blood, and urine test for sugar and hematest results, -environmental situations -client/family comments r/t clients care -behaviors r/t the plan of care 3. ambulation, positioning and turning 4. transportation of client within a facility 5. personal hygiene and elimination, including vaginal irrigation's and cleansing enemas 6. feeding, cutting up of food, or placing of meal trays 7. socialization activities 8. ADLs 9. reinforcement of health teaching planned and/or provided by the RN Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers -Discretionary Tasks § 224.8 (b) - correct answer (b) 1. in addition to general criteria for delegation outlined in 224.6 of this title, the nursing tasks which follow in paragraph (2) of this subsection may be delegated to an unlicensed person only (A) if the RN delegating the task is directly responsible for the nursing care given to the client; (B) if the agency, facility, or institution employing unlicensed personnel follows a current protocol for the instruction and training of unlicensed personnel performing nursing tasks under this subsection and that the protocol is developed with input by RNs currently employed in the facility and includes: (i) the manner in which the instruction addresses the complexity of the delegated task (ii) the manner in which the unlicensed person demonstrates competency of the delegated task (iii) the mechanism for reevaluation of the competency and; (iv) an established mechanism for identifying those individuals to whom nursing tasks under this subsection may be delegated; and Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers -insert a urinary cath -admin meds (excluding IV med in some states) to AP,CNA,PCA -ADLS -bathing -grooming -dressing -toileting -ambulating -feeding WITHOUT swallow precautions -positioning -routine tasks -bed making -specimen collection -intake and output -vital signs for STABLE patients Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers 6 step decision making model for determining nursing scope of practice - correct answer Step 1 Is the act consistent with the Texas Nursing Practice Act (NPA)? Do the Board's rules or positions statements address this specific act? -If "Yes," continue to Step 2. -If "No," stop. Step 2 Is the activity appropriately authorized by valid order/protocol and in accordance with established policies and procedures? -If "Yes," continue to Step 3. -If "No," stop. Step 3 Is the act supported by either research reported in nursing and health- related literature or in scope of practice statements by national nursing organizations? -If "Yes, continue to Step 4. -If "No," stop. Ethical issues, legal issues, Texas nurse practice act and nurse jurisprudence exam, Delegation & prioritization of client care Questions And Answers Step 4 Do you possess the required knowledge and have you demonstrated the competency required to carry out this activity safely? -If "Yes," continue to Step 5. -If "No," stop. Step 5 Would a reasonable and prudent nurse perform this activity in this setting? -If "Yes," continue to Step 6. -If "No," stop. Step 6 Are you prepared to assume accountability for the provision of safe care and the outcome of the care rendered? -If "Yes," perform the activity. -If "No," stop