ETHICS AND COMPETENCE

Ethical Leadership and Continuing Competence in Nursing Chris OConnell Western Governors University

ETHICS AND COMPETENCE Introduction Issues of patient and nurse autonomy, informed consent, end-of-life care and advanced health care directives are frequent sources of ethical dilemmas in practice faced by the professional nurse. The purpose of this paper is to examine and discuss these issues within the context of the scenario presented. State Regulations and Nursing Standards Advocacy is a cornerstone of nursingboth in theory and in practice. Advocacy in the form of protecting consumers is of the highest priority of the California Registered Nursing Program (RNP) 1. The Business and Professions Code grants the RNP broad authority with regard to the regulation of nursing practice and enforcement of the states Nursing Practice Act (NPA). The NPA clearly identifies patient advocacy as a standard of professional nursing

practice ("Title 16, california," n.d.). The specific regulation in the Act states that the competent nurse: Acts as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided. (Section 1443.5 (6), Standards of Competent Performance) Code of Ethics The case presents the ethical dilemma of initiating treatment in order to prolong Mr. Es life versus adhering to his previously documented wishes with regard to such treatment

Formerly known as the Board of Registered Nursing (BRN). Governor Brown vetoed SB538, which would have extended the BRNs sunset date. The CA Legislature must enact legislation to re-form the BRN.

ETHICS AND COMPETENCE

protecting his health vs. protecting his rights. The dilemma in this case is further complicated by the fact that the patients advance directive is not in the chart for his current hospitalization. Many facilities have policies in place which require staff to intervene with life-sustaining measures in the absence of such a document until such time that a physician writes a do not resuscitate order. In its Guide to the Code of Ethics for Nurses: Interpretation and Application (Fowler, M. 2008) the American Nurses Association recognizes nine provisions. The first three provisions can be characterized as patient-centered in nature, and therefore any one would be applicable in this case. However, Provision 3 states, The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient, and is therefore most fitting in the case of Mr. E. (p. 23). Impact of Code The NPA of California and the Code of Ethics for Nurses clearly outline advocacy as a essential aspect of competent nursing practice. Protecting Mr. Es health does not necessarily mean prolonging his life. In this case, protecting the rights and dignity of the patient supersede prolonging his life. Therefore, the nurse in this case study would be both legally and ethically compelled to advocate for upholding the patients prior decision to decline the ventilator, and to act to protect his privacy and dignity. Ethics of Putting Patient on Ventilator According to the American Medical Associations Code of Medical Ethics, The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the preferences of the patient should prevail (AMA, 1996). The wishes of Mr. E. are known as evidenced in his advance healthcare directive. Therefore, the

ETHICS AND COMPETENCE physician would be in violation of his ethical code if he proceeded with intubation and mechanical ventilation and the nurse would be legally and ethically bound to advocate for alternatives to this treatment. Ethics of Authorizing Ventilator The AMAs Code of Medical Ethics goes on to state: Physicians should provide all relevant medical information and explain to surrogate decision makers that decisions regarding withholding or withdrawing lifesustaining treatment should be based on substituted judgment (what the patient would

have decided) when there is evidence of the patients preferences and values. In making a substituted judgment, decision makers may consider the patients advance directive (if any); the patients values about life and the way it should be lived; and the patients attitudes towards sickness, suffering, medical procedures, and death (AMA, 1996). While Mr. H. is not the designated surrogate identified in the advance directive, he is family to Mr. E. In addition, Mr. B. has already informed Mr. H. of the patients condition. From an ethical standpoint, an argument could be made that both the nurse and the physician could further inform Mr. H. of Mr. Es condition in the absence of his designated proctor. However, Mr. B. is en route to the hospital, so while he may choose to consult privately with his nephew, it would be unethical for the physician or the nurse to solicit Mr. Bs consent for intubation or for Mr. B. to provide such consent. Role of Nurse Autonomy Nurse autonomy is inherent in the CA NPAthough not addressed explicitly. However, the RNP later explained that: In Section 2725(a), the Legislature expressly declared its intent to provide clear legal

ETHICS AND COMPETENCE authority for functions and procedures which have common acceptance and usage. Registered nurses must recognize that the application of nursing process functions is common nursing practice which does not require a standardized procedure (RNP, 2011). Effects of Board of Nursing Regulations on Autonomy Autonomy can be described as independence or authority, so the nurse clearly has the autonomy to take steps to advocate for the patienta nursing process function (RNP, 2011).

In this context, the nurse should consult with the physician on the appropriateness of the plan and protecting the patients privacy, consult with social services and provide counsel to the family with regard to the patients wishes. Nurse Obligation The patient in this case study was clear in his wish to decline invasive, life-sustaining measures in the course of his careregardless of his current mental state. His wishes, however, are not currently documented in his chart. Still, the nurse is aware of his wishes and the NPA, Code of Ethics for Nurses and state codes compel the nurse to advocate on behalf of this patient and act to protect his rights and privacy. Extent of Nurse Obligation The Health Information Protection and Portability Act of 1996 (HIPPA) provides for the protection of patients privacy. If the physician provided protected information to the nephew without the consent of either Mr. E. or Mr. B., it is in violation of HIPPA. Further, Section 1280.15 of the California Health and Safety Code requires healthcare facilities to both prevent and report violations of patient privacy. Both the healthcare facility and the provider can be assessed substantial fines for violations of patient privacy. It is the obligation of the nurse to act in a manner which serves to protect the rights of the patient in

ETHICS AND COMPETENCE matters of healthcare, as well as adherence to current health code laws, and therefore to report the violation appropriately. Accountability The American Nurses Association (ANA) noted that Nursing is the pivotal health care

profession, highly valued for its specialized knowledge, skill, and caring in improving the health status of the public and ensuring safe, effective, quality care (ANA, 2002). In this case, the quality and safety of the patients care can be measured by asking, To what extent were his rights and wishes protected? The competence of the nurse can be measured by asking, To what extent did the nurse act on his professional and ethical obligations to protect this patient? There are several dignified, credible and ethical alternatives to violating those rights and wishes at the end of his life. The nurse, ultimately, is responsible and accountable for ensuring that those alternatives are considered. The nurse has direct professional, ethical and moral accountability for the protection of this patients rights and the outcome of his care. Failure to advocate for this patient would violate the nurses practice act, his ethical code and it would violate the social contract that nursing has with the greater society.

ETHICS AND COMPETENCE References AMA. (1996, June). Ama code of medical ethics. opinion 2.20 - withholding or withdrawing life-sustaining medical treatment. Retrieved from http://www.ama- assn.org/ama/ pub/ physician-resources/medical-ethics/code-medical-ethics/opinion220.page? January 15, 2012. American Nurses Association. (2010). Nursing's social policy statement: An overview. In Nursing's social policy statement: The essence of the profession (p. 1). Silver Spring, MD: ANA. California Department of Consumer Affairs, Registered Nursing Program. (n.d.). Title 16,

california code of regulations; Article 4. grounds for discipline, disciplinary proceedings and rehabilitation. Retrieved from website: http://www.rn.ca.gov January 7, 2012. Registered Nursing Program. CA Department of Consumer Affairs, Registered Nursing Program. (2011). An explanation of the scope of rn practice including standardized proecedures (NPR-B-03). Retrieved from website: http://www.rn.ca.gov/pdfs/regulations /npr-b-03.pdf January 13, 2012. Twomey, J. G. (2008). Provision three. In M. Fowler (Ed.), Guide to the code of ethics for nurses: Interpretation and application (pp. 23-39). Silver Spring, MD: American Nurses Association.