Question:

Essential Questions

• How does the nurse adhere to and elevate standards or the profession?
• Which aspects of ethical principles and nursing standards are most evident in practice?
• What are the external factors that influence nursing standards?
• What are some of the most notable recent federal laws transforming healthcare?

Introduction

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care. (American Nurses Association [ANA], n.d.)

Nurses at pinning ceremonies often recite the Florence Nightingale Pledge. The recitation occurs at a time of excitement and relief as students graduate from a nursing program. The pledge represents the ethical principles of the profession, much as the Hippocratic Oath is for the medical profession. Nurses publicly announce a commitment to the avoidance of deleterious behavior (i.e., do no harm to themselves or patients) and devotion to confidentiality and welfare of those under their care. The pledge is a sign of dedication to ethical principles, professional accountability, and adherence to standards of practice. Perhaps, few recognize the true strength of this responsibility at the time of graduation. The loyalty to the profession calls nurses to have ongoing professional development and devotion to elevate the profession.

Nightingale, viewed as the founder of professional nursing, approached nursing care through the compilation of information regarding patient care. In other words, Nightingale is the true founder of data-driven, evidence-based nursing practice. Standards of care focused on clean air and the surrounding environment, along with nutrition and sleep. She documented statistical data to prove the standards saved lives and hastened recovery. Her diligence drove the development of standardization of practice evident today. In addition, Nightingale advocated for the ongoing development of nurses and adherence to ethical principles of practice.

Innumerable activities of nurses arise from the development of professional accountability, adherence to standards of practice, and ongoing professional development. These foundational aspects of nursing evolve from thinking abilities, acceptance of ethical principles, and understanding professional obligations. This chapter will explore these aspects, along with the interplay of scope and standards of practice. The impact of two nonprofit organizations—the Institute of Medicine and The Joint Commission—on quality, safety, and health promotion in health care is part of the content. Legislative actions resulting in dynamic health care changes are relevant materials, along with a projection to future changes.

Critical Thinking, Clinical Reasoning, and Clinical Judgment

Human brains grow and develop pathways for speech, thought, and logical analysis. Sciences studying these processes note differences in abilities over time and life experiences. Although people entering nursing have thinking abilities, nursing requires the development of additional ways of thinking: critical thinking, clinical reasoning, and clinical judgment. The ways of thinking begin in prelicensure education and grow with experience and ongoing professional development. One of the aspects of baccalaureate education is the emphasis on the ways of thinking.

Critical Thinking

Critical thinking in nursing is the ability to apply the nursing process effectively and purposefully to an identified problem. Since becoming a student, the nurse learns to apply logical and empirical reasoning when making important decisions regarding patient care. Much thought about assessment, analysis of information, determining desired outcomes, and planning occurs before interventions. Nursing experience and ongoing professional and academic development, such as baccalaureate education and beyond, increase the thought process involved. Many characteristics contribute to the development of a critical thinker including the following traits:

• Inquisitiveness—the nurse continually seeks new solutions and knowledge related to the given problem
• Systematicity—organized work process and flow
• Analyticity—utilization and application of evidence-based practice to perform patient care
• Open-mindedness—the ability to be tolerant of opposing views and consider other perspectives and proposals
• Confidence—trust in one’s own capabilities

These elements, taught and discussed in nursing programs, receive honing at the bedside through gained experiences (Gul & Boman, 2006). Systematicity enhances the nurse’s ability to put intuitiveness, analytical abilities, tolerance, and confidence into practice. Formal approaches to organized workflow arose from theories among other disciplines. For example, by studying general system’s theory, nurses observed the cause and effect nature of nursing actions on the patient outcomes. By applying scientific approach theories, nurses organized care based on the classic scientific methods of observation, hypothesis, experimentation, and corroboration (Humphris, 1979). With the passage of time, nurses advanced the profession by developing other theories of approach. Henderson built on Nightingale’s concepts to identify 14 basic human needs affecting patient recovery and independence, launching modern-day nursing approaches (Crossan & Robb, 1998; Dijkstra, Buist, & Dassen, 1998). The nursing process became prominent as the nurse’s systematic approach after the 1961 publication of Orlando’s The Dynamic Nurse-Patient Relationship, advocating the deliberative nursing process (Crossan & Robb, 1998; Faust, 2002; Kim, 1994; Potter & Brockenhauer, 2000; Potter & Tinker, 2000; Rosenthal, 1996).

No universal definition of critical thinking exists for the nursing profession. Use of the term is often interchangeable with the terms clinical judgment or clinical reasoning (Alfaro-LeFevre, 2017). The terms reflect nursing perceptiveness and position the nurse to use “clinical judgement as rational and directed only toward resolutions of problems and clearly defined ends” (Benner, Sutphen, Leonard, & Day, 2010, p. 200). The American Association of Colleges of Nursing’s (AACN) publication, The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008), distinguishes the three terms (see Table 4.1). AACN (2008)denotes critical thinking as a decision-making process involving “questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity” (p. v). Clinical reasoning extends the process to integrate and analyze information and make decisions about patient care (AACN, 2008). Clinical judgment reflects the end or outcome of critical thinking and clinical reasoning (AACN, 2008). To avoid error and to meet the needs of patients and families, nurses must attentively use these three ways of thinking along with the nursing process (Walton, 2017). Rather than relying on reaction to a situation, intertwining the use of these skills is part of professional responsibility and quality of nursing care (Carvalho et al., 2017). The nurse uses a higher level of cognitive skills and communication/collaboration abilities to recognize and respond in a timely fashion to alterations, prediction of outcomes, and selection of the best logical action for an individual’s unique situation (Carvalho et al., 2017; Papp et al., 2014; Peeters & Boddu, 2016).

Table 4.1

Distinguishing Among Ways of Thinking Terms

Term	Definition Summary
Critical Thinking	Decision-making process
Clinical Reasoning	Extends the decision-making process to integrate and analyze information, and then make decisions about patient care
Clinical Judgment	End or outcome of critical thinking and clinical reasoning

Note. (American Association of Colleges of Nursing, 2008)

Intellectual Traits

Those who wish to become nurses arrive at school with a wide range of educational and life experiences. A challenge for nurse educators is to embrace the nursing students’ backgrounds and build on preexisting strengths while redirecting weaker areas that need improvement. The presence of intuition and logic for development of critical problem-solving abilities is indispensable in the student. Alfaro-LeFevre (2017), a leader in these concepts, compared thinking and critical thinking. “Critical thinking is controlled and purposeful, using well-reasoned strategies to get the results you need” (Alfaro-LeFevre, 2017, p. 5), whereas, conventional thinking can be mindless and routine, like the act of walking.

Ideally, intellectual traits, such as empathy, integrity, and reason, mature as critical-thinking dynamics expand. Nursing requires the ability to reason to analyze situations logically; however, as the professional develops, the ability to reason incorporates new insights, often from other disciplines. For example, as the baccalaureate nurse grows, logical analyses from sociopsychology, education, theology, and natural sciences influence the nurse’s perspective and resources. Integrity, or honesty, is an expectation of a nurse, and yet nursing students are caught cheating on examinations and assignments as well as plagiarizing papers. Recognizing the importance of respect and the need to protect integrity helps student nurses grow in their understanding of the ways of thinking and professionalism. Last, but not least, empathy is a voice of caring by the nurse. Nurses cultivate therapeutic relationships to relate to and understand the thoughts and feeling of patients and families. Empathy involves awareness and reduction of personal attitudes, bias, and stereotyping. Patients and families need to feel safe to express feelings, thoughts, and concerns without fear of a negative backlash in care. Emotional support fosters patient health. Maya Angelou noted, “As a nurse, we have the opportunity to heal the heart, mind, soul, and body of our patients, their families, and ourselves. They may not remember your name but they will never forget the way you made them feel” (American Association of Post-Acute Care Nursing, 2016, para. 9).

Measureable Behaviors

Nursing educators must coach students as advisors and role models, and monitor student behaviors. Likewise, preceptors and managers evaluate the novice nurse or new employee for evidence of critical-thinking abilities through discussions and results of care delivery. Empathy, use of the nursing process, reflective thinking, and use of evidence-based practice should be apparent. When nurses apply critical-thinking abilities, ethical reasoning, and honesty, integrity and ethical analysis are present in care delivery discussions and outcomes. Without compassion, the caregiver can become indifferent to the needs of the patient. This trait is challenging to foster if not already present. Another important character trait for nurses to possess is humility. Sometimes students and newly licensed nurses believe they already possess the intuition, logical thinking/problem-solving skills, and compassion needed for the profession, and do not wish to consult with others before caregiving. This becomes dangerous if the novice forges ahead in care decisions and delivery without consulting the coach. Listening and submitting to experienced nurses to determine the best care is important as novices learn to discern the complexity of the patient situation. Similarly, new nurses should exercise caution and avoid being a sponge, absorbing everything from the experienced nurses. Observing, questioning, and responding to questions with experienced nurses helps in the growth of critical-thinking and clinical-judgment skills; hovices may be eager for credibility regarding knowledge and skill abilities, along with independence, and may find patience taxed by the need for consultations. Because a portion of critical thinking, clinical reasoning, and judgment behaviors are cognitive or affective, measurement of the behaviors is a great challenge to nursing educators and health care administrators. Evidence of psychomotor behaviors is easier to obtain and analyze. Those in such evaluative positions seek the best practice for measuring these behaviors in professional publications and through networking. While working through the nursing program, students experience multiple assignments to enhance and evaluate skills in critical thinking. The novice experiences an evaluative period as well. More recently, internship programs serve to provide mentorship and monitoring as the novice grows.

Building Critical Thinking Skills

Building critical-thinking skills occur through the development of clinical reasoning and clinical judgment and vice versa. The process is highly interactive. The skills, guided by standards and scope of practice, codes of ethics, and laws, complement the nurse’s grounding in the nursing process and evidence-based practice. The process of building critical-thinking skills requires dedication to awareness, reflection, interpretation, and implementation. According to Alfaro-LeFevre (2017), the development of critical-thinking skill requires the nurse to gain insight and self-awareness, build trust, establish mutual communication in relationships, use evidence-based references, commit to the attitudes, knowledge and skills required for critical thinking, and seek formal and informal feedback of thinking and actions taken. Often, critical-thinking skill assignments use reflective narration to enhance self-awareness, communication abilities, and reflective evaluation of actions and outcomes. Nursing educators and preceptors often ask the nursing novices to break the nursing process into subcomponents in which the novice comes to the experienced nurses before taking the next process step. This aids the interpretation process before implementation of direct care. Sharing patient assessment findings with experienced nurses allows intentional time for reflection and interpretation of the implications of the information. This also increases effectiveness in oral and written communication skills. The time out in the process allows input from the seasoned nurses along with methods to draw out the novice’s critical reasoning with questions about the assessment, analysis, and plans for care. Nurses’ abilities to state rationale have been critical to the profession. Now, the rationale has expanded from textbook regurgitations of information to reasoning applicable to the individual patient’s condition. Socratic questioning of “why” may occur, as in, “Why do you think this is the best intervention?” or, “Help me understand why you think that this assessment data means that the patient is better than the previous assessment.” The nursing process continues onward to the interventions step after agreement occurs regarding the novice’s assessment, analysis, nursing diagnosis, outcomes identification, and planning. The educator or coach may accompany the novice through the implementation process for safety and quality care, depending on the previously assessed skill level of the novice. The mentoring communications resume to evaluate the outcomes of care given and to make decisions for follow-up. In a nursing program, students may have a journaling assignment to reflect further on the events of the day.

Clinical Reasoning

Benner’s 1984 landmark model development regarding growth process from layperson into a nursing role demonstrated that clinical reasoning does not occur overnight. The approach of novice to expert denotes the need to coach new nurses throughout the nursing education process and onward in licensed, clinical practice. In 2010, Benner, Stuphen, Leonard, and Day defined clinical reasoning as the “ability to reason about a clinical situation as it unfolds as well as patient and family concerns than the context” (p. 46). Baccalaureate preparation provides exposure and application of multiple ways of thinking and reasoning. Measures for learning clinical reasoning and clinical judgment skills are within present-day prelicensure nursing programs. Still, experienced, baccalaureate-prepared nurses coach newly licensed nurses as they transition student skills to licensed practice, helping them to grow in clinical reasoning and clinical judgment abilities, as ongoing enhancement of these skills is part of professional accountability. The dynamic and complexity of patient care and use of technology today demand that the professional caregiver quickly employs these skills to prevent health care errors and omissions, incomplete care, and failure to recognize or respond to failing clinical status.

Nursing Process

The nursing process is a decision-making process and provides the foundation for the profession’s problem-solving abilities. The nursing process implies the use of critical thinking, clinical reasoning, and clinical judgment. This critical thinking and reasoning model adopted by the American Nurses Association (ANA), prevails in all ANA standards and scopes of practices. The Nursing Scope and Standards of Performance and Standards of Clinical Practice (ANA, 2015) is the most recent scope and standard of practice publication, which applies to all nurses. The nursing process is found in Standards 1 through 6 of the publication. This edition identifies the components of the nursing process as assessment, diagnosis, outcomes identification, planning, implementation, and evaluation (see Figure 4.1).

Figure 4.1

The Nursing Process

The nursing process usually proceeds circularly from the assessment component through evaluation, although some perceive the process as proceeding top to bottom, starting again with the assessment moving down to evaluation. With either perception, the process is ongoing. Once the nurse reaches evaluation, the process resets or loops back to the assessment step. Meanwhile, a flow of information exchanges occurs between each component with all the other components. This information flow or feedback directs the nurse’s return to previous process steps. Information gleaned from one process step influences the others. The feedback loops require the nurse to recognize the complexity of patient conditions and independently employ critical thinking, clinical reasoning, and clinical judgment. Through experience and ongoing education, nurses increase critical-thinking abilities in the use of the nursing process. Baccalaureate education of nurses expands students’ understanding using theory from other disciplines, evidence-based practice, health promotion, safety and quality measures, genomics, informatics, and nursing along with community and global awareness. For example, the BSN-prepared nurse has more background incorporating theories regarding ethics, change, leadership, systems, and social justice, which influence critical perceptions of situations. The emphasis on evidence-based practice is notable. The ADN-prepared nurse incorporates knowledge of science into care for patients and families. The BSN-prepared nurse integrates science and other disciplines and critically appraises published research to use as a foundation of evidence-based solutions when caring for patients, families, and communities (National League for Nursing, 2010). This education enhances the nurse’s critical-thinking abilities within the use of the nursing process.

Ethical Reasoning

The awareness, reflection, and interpretation processes of critical thinking incorporate the nurse’s personal moral and professional values. As the nurse advances in professional development, questions will arise about whether something feels like the correct thing to do, whether an action is legal, whether fair and equitable treatment is being provided, and whether one is avoiding his or her personal bias. Determining whether any health disparities are present requires analyses of psychosocial, cultural, and spiritual facets for the nurse, patient, and family. As the nurse broadens in ethical understanding and social justice principles, clinical reasoning skills expand. Implementing ethical choices and experiencing results that promote human health and well-being reinforces the change in perspective.

Clinical Judgment

Alfaro-LeFevre (2017) defines clinical judgment as the result or outcome of critical thinking and clinical reasoning. Tanner (2006) reviewed nearly 200 studies of clinical judgment, arrived at five conclusions, and developed a model of clinical judgment (see Figure 4.2). Tanner fashioned the model to depict the noticing, interpreting, responding, and reflecting behaviors of clinical judgment in nursing. The nurse must be aware of the situation or notice what is happening. Then the nurse interprets the stimuli using analytic reasoning, ethical reasoning, narrative skills, and intuition. At that point, the nurse responds by choosing evidence-based and analyzed purposeful actions. The final step is the reflection on the action and lessons learned by the process and outcomes.

Figure 4.2

Tanner’s Five Conclusions

Note. Adapted from“Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing,” by C. Tanner, 2006, Journal of Nursing Education, 45(6), p. 204. Copyright 2006 by the Journal of Nursing Education.

Ethical Practice in Nursing

Philosophies of life result from values, assumptions, and beliefs gleaned from influences of childhood upbringing, life experiences, culture, spirituality, peers, and community. The individual’s philosophy drives decision making when faced with ethical or unethical behaviors. Nurses have the additional influence of their profession’s philosophies regarding ethical values and actions. Ethical issues occur in every health care environment; thus, they are part of every nurse’s practice. To uphold professional standards, nurses require knowledge, skills, and resources (Rushton & Broome, 2015). Ethical issues arise from various viewpoints about the differences between right and wrong. The viewpoints are common among society and religious beliefs as moral truths. For example, the Grand Canyon University (GCU) Ethical Positions Statement reflects this value. The position statement supports that knowing the difference between right and wrong reflects Christian beliefs, values, and practices and that those who follow Christ “should strive to live in a way that Christ lived both in private and in public” (Grand Canyon University [GCU], n.d., p. 12). Because situations involving ethics integrate within nursing practice, the nurse should understand ethical principles, theories of ethics/morality, applications to nursing practice, and components of ethical situational analysis. Baccalaureate education provides opportunities to expand knowledge, skills, and tools to face ethical issues and elevate professional standards.

Ethical Principles

Ethical principles are fundamental truths or foundational ethical values. Eight principles common within health care ethics are autonomy, beneficence, fidelity, justice, nonmaleficence, privacy,confidentiality, respect, and veracity. Ethical principles are not law, but the principles have become duties of the health care profession (see Table 4.2). The public expects nurses to demonstrate good moral character. Nurses exercise choice to follow the principles as a part of the profession’s inherent respect for humankind. Choosing to follow ethical principles displays the nurse’s commitment to the profession and those receiving health care. GCU supports such respect. “As a Christian institution, GCU affirms that every human being is precious to God and should be treated with the dignity and respect. …The university affirms the sanctity of human life and the intrinsic value of every human being” (GCU, n.d., p. 6). Drought (2002) noted that nurses function at the core of humankind with a practice tied to the vulnerability of the patient and morality.

Table 4.2

Ethical Principles

Ethical Principle	Concepts/Duties
Autonomy	Supporting a person’s right to self-determination; respecting a person’s rights, values, and choices
Beneficence	Doing good; actions benefiting others versus risk of harm; best care
Fidelity	Loyalty; keeping promises
Justice	Sense of fairness and equity of distribution; what is deserved; no favoritism
Nonmaleficence	Doing no harm; not to intentionally inflict harm; consideration for the degree of risk
Privacy and Confidentiality	Right to control one’s personal information; self-determination for the amount of private information to reveal; respect for and nonrevelation of a person’s private and sensitive information
Respect	Treating every person as a worthy individual; honoring autonomy and protection for those with diminished autonomy
Veracity	Truthfulness; honesty; truthful disclosure of information; integrity

Nursing Ethics in Practice

Part of growth as a nurse is the application of an inner conscious or moral compass into professional practice (Eklund, 2016; Lachman, 2009; Lachman, 2012). According to Lachman (2016), a code of ethical conduct delivers “the legal and professional outline for answerable and accountable practices across the profession” (p. 429). The most prominent code of ethics for nurses in the United States is the recently revised ANA Code of Ethics with Interpretive Statements (2015). Ethical duties of registered nurses are declared through nine provisions (see Table 4.3). Interpretive statements provide a broader basis for understanding how to apply the provisions (Rushton & Broome, 2015; Lachman, 2015; Winland-Brown, Lachman & Swanson, 2015). These ethical principles are prominent in the interpretive statements.

Table 4.3

Provisions of the ANA Code of Ethics for Nurses

Provision 1	The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
Provision 2	The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
Provision 3	The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Provision 4	The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
Provision 5	The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
Provision 6	The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
Provision 7	The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
Provision 8	The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
Provision 9	The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Note. Adapted from “Code of Ethics for Nurses with Interpretive Statements,” by the ANA, 2015, p. v. Copyright 2015 by the ANA.

Ethical codes for nurses are not limited to the ANA’s Code of Ethics for Nurses with Interpretive Statements (2015). Specialty organizations may have their code of ethics; moreover, nursing is a global profession. For example, the International Council of Nurses (ICN) focuses on quality nursing care and health policies worldwide.The ICN Code of Ethics for Nurses (2012) stated that four elements frame the standards of conduct: “nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers” (p. 4).

Nurses Role in Ethics

Pressures and anxiety occur when ethical issues arise. Nurses often feel stress when arriving at or participating in decisions attempting to resolve ethical dilemmas. In these instances, nurses greatly influence the health care environment by acting as an advocate for ethical decision making. “Nurses encounter these challenges in many settings and are uniquely positioned to speak up to influence decisions that will lead to the right actions and to establishing an ethical practice environment” (Cipriano, 2015, p. 3). Nurses face pressures because of both societal and rapid health care system transformations (Johns Hopkins Berman Institute of Bioethics, 2014).

Nurses feel these pressures and the intense array of ethical issues that they raise. At the same time, research shows that patients and health care organizations fare better when nurses can be reflective, and are supported in their work environments in the practice of high-quality, ethical care (para 2).

Pressures arise from issues regarding informed consent, questionable research practices, end-of-life care, and many other types of additional ethical scenarios. Drought (2002) noted, “The human intimacy and vulnerability that we are privileged to witness creates a duty to protect the privacy of the patient and the confidential nature of what we see and learn” (p. 239). Nursing was founded on the aspects of services to others. Service and respect for others remain a constant nursing value while giving care across the life cycle (Rushton & Broome, 2015). Nurses are empowered to be the patient’s voice or advocate, protecting ethical principles of autonomy, nonmaleficence, confidentiality, and other ethical principles.

Different Levels of Nursing Ethics

Opportunities for nursing to employ ethical behaviors occur at every level of health care: patient, organization, professional, state, national, and international levels. The nurse is empowered at the patient level as difficult patient situations occur, such as informed consent, treatment choices, end-of-life decisions, cultural differences, and family versus patient preferences. At the organizational level, the environment reflects the ethical beliefs of the organization. In larger organizations, more opportunities exist for nurses to collaborate with other nurses and disciplines when facing ethical issues. The resources are generally more abundant at larger organizations, whereas smaller facilities may have fewer pairs of eyes to note an issue. The number and types of issues may be more diverse in larger organizations, such as metropolitan teaching or research facilities; however, no matter what the size of the organization, everyone must be aware of possible ethical issues and be willing to act to prevent harm. No one wishes to be in situations in which such harm occurs. The classic case of murderous Dr. Michael Swango conveys ethics at the organizational level; people in multiple states who worked at hospitals with Dr. Swango reported feeling that something was not right (Stewart, 1999). If the ethical conduct is not congruent with the ethical code of conduct governing nurses and health care, a far-reaching ethical dilemma arises for both the nurse and the patient for best care decisions. Additionally, the nurse supports the patient during conflicts with greater ease if he or she knows that the organization supports patient advocacy. At a professional level, empowerment occurs through advocacy efforts of national and international organizations. On a political level, nurses are of such a large number that the profession amasses a large voice that politicians listen to on local, state, national, and global levels.

The ANA Code of Ethics (2015) defines metaethics as the “nature of ethics and moral reasoning: right vs. wrong; good vs. evil; normative ethics; ethics of right and wrong in human action—what we ought to do; good evil-what we ought to seek to be” (p. 15). Studies on theories of metaethics abound, but the most common theories influencing health care are deontology, utilitarianism, and virtue ethics (see Table 4.4). The theories provide guidance toward various perceptions of problems versus a one perception fits all approach. These theories are foundational to codes of ethics and logical reasoning.

Table 4.4

Theories of Morality

Theories of Morality	Main Concepts
Deontology	Duty-based; focuses on obligation to others. In the 18th century, Immanuel Kant emphasized respect for the dignity and worth of every individual. Under deontology, actions are not a means to the end, but rather based on right action for the social duty of treating others with respect, dignity, and worth.
Utilitarianism	Outcome based; in other words, it centers on the end outcome of human actions. In the 19th century, John Stuart Mill concentrated on actions that would result in the best outcome for the largest number of people; thus, simplified as actions for the greater good. The end justifies the means.
Virtue Ethics	Character-based; agent based; in other words, whether a good, honest, or generous person would perform the act in question. Virtue ethics is not action-based as in the two previous theories.

Ethical Analysis

An ethical dilemma is a situation in which a choice is required among options, none of which will resolve the situation in the most favorable ethical manner. Applied ethics are the various approaches to ethical dilemmas. Applied ethics “wrestles with questions of right, wrong, good, and evil in a specific realm of human actions, such as nursing, business, or law” (ANA, 2015, p. 15). This involves the use of logical reasoning, ethical analysis, and in the case of nursing, critical thinking and clinical judgment. Ethical dilemmas may result from issues such as whether to continue life-sustaining actions or end-of-life treatment. Conflicts can occur involving family dynamics, religious and cultural beliefs, and other factors. Sometimes situations result in a convening of an institution’s ethics committee, composed of multidiscipline representation. Issues are forwarded to the committee’s attention through institutional policy and/or chain of command. Nurses are encouraged to participate on ethics committees if an opportunity arises. The nurse is responsible for learning the process for that setting, including the existence of an ethics committee, committee composition, times of meetings, and access to the committee should the need to convene occur. Moreover, the nurse is responsible for knowing the members of the chain of command because when issues and dilemmas occur, they are the timeliest and most closely connected resources to the nurse for assistance; however, not every ethical analysis is handled within a committee structure. Ethical dilemma analysis usually uses the following components: medical indication for treatment, risk-benefit analyses, alternatives, patient preferences, quality of life predictions, and pertinent external factors. The analysis process applies components from the theories of morality. The nurse’s role is an advocate for the patient.

Check for Understanding

1. How are ethical dilemmas analyzed where you are employed?
2. Whom do you contact when an ethical dilemma occurs in the workplace?

Common Ethical Dilemmas

Nurses encounter a variety of ethical dilemmas. Every dilemma must be resolved on a case-by-case basis. There are no magical standard answers to these situations.

Informed Consent: Will the outcome be affected or rights violated if the sparse information is provided to a patient? How is the nurse certain of informed consent when the person has dementia or an intellectual disability? What happens when an option is best, but not affordable? What happens when a viable option is not presented because the practitioner does not believe it is best for the patient? When does the nurse intercede?

End of Life: How is quality of life determined? How is pain relief determined? How are patient preferences determined without prior conversations with a surrogate decision-maker or advanced directives? When families conflict over end-of-life decisions, how is this resolved? If a fetus is involved, how is conflict resolved over the possible life of one over another? What is the nurse’s role?

Impaired Caregivers: Evidence of a coworker’s use of mood-altering substances in the workplace demands immediate intervention. Nevertheless, what does the nurse do with suspicions without evidence? What if the nurse does nothing and a patient is harmed? What if the nurse is wrong; what happens to the working relationship?

Staffing: How do patient acuity and skill mix affect the ability to protect patient rights, treatment complexities, and educational needs? How does the nurse avoid becoming jaded or worn? How is quality care versus economic cost measured and weighed?

Professional Obligation and Responsible Care

Lifelong Learning

Nurses have a responsibility to remain current in nursing and health care practices. Laal (2011) defined lifelong learning as a means of learning that “should take place at all stages of life cycle (from the cradle to the grave) and, in more recent versions that it should be life-wide; that is embedded in all life contexts from the school to the workplace, the home and the community” (p. 471). Lifelong learning for nurses encompasses many formats. Formal education in the form of higher collegiate degree is one method. Continuing education, workshops, conferences, and summits also contribute to expanding nursing knowledge and skills. Most states require evidence of ongoing education for continued licensure, reinforcing the expectation of ongoing development. These boards, charged with protecting the public, require continuing education credits as evidence of protection. A nurse practicing in a state without these requirements has expectations from peers and the profession for current, safe, quality practice through lifelong learning. Reading professional journals on a routine basis supplies current, relevant information to the nurse. For example, networking with other nurses through professional organizations informs nurses regarding emerging issues. Keeping abreast of current political information and news regarding health care is still another method of lifelong learning. Lifelong learning is vital because it keeps the patient, nurse, and families safer through growth in knowledge and skills for assessment and awareness of changes in evidence-based practice. Education helps nurses advance quality care and health promotion. Learning empowers the nurse and enhances credibility with the public, peers, and other disciplines.

Empowerment

“Because nurses are allowed to touch people physically and emotionally in ways others cannot, that level of trust imposes on nurses certain obligations not always shared by the general public” (Lanier, 2016, p. 18). The codes of ethics detail a nurse’s obligations. “Licensure is a covenant, between privileges upon nurses as well as duties” (Drought, 2002, p. 238). The trust of the public and privileges of being a registered nurse demand the provision of safe, quality, ethical care. This mandate necessitates keeping abreast of changes in technology, politics, scientific discoveries, health care treatment trends, and ethical issues. Also, choosing to practice in settings that support and value one’s beliefs provides additional inspiration, confidence, and empowerment. The nurse who remains current to the dynamics of the profession and health care is empowered to trigger or participate in change.

Refreshing the Basics: Laws

Legal system concepts are foundational to nursing practice. For some, this content may be familiar, offering a refresher of current understanding, while for others, this may be new. Because nursing practice is both permissible by law and affected by the various areas of law, the following aspects should be reviewed to confirm knowledge and understanding.

The United States legal system contains laws arising from three main sources: 1) judicial or common law, 2) legislative law, and 3) constitutional law. An overview of privacy in health care can aid in better understanding these sources. Constitutional laws reflect rights stemming from the federal and state constitutions. Long before the Health Insurance Portability and Affordability Act of 1996 (HIPAA), a federal constitutional right to privacy was recognized in the legal system. Unfortunately, laws do not address specific scenarios and are open to interpretation, which in turn leaves these interpretations of the law open to debate and sometimes leads to court cases. Legislation and standards of practice uphold nurses’ obligation to maintain a patient’s right to privacy and confidentiality.

Passage of legislation, also known as statutes, provides guidelines that are more specific. In this case, the United States Congress passed HIPAA to define and refine to whom disclosure of personal medical information was permissible and under which circumstances. HIPAA was not restricted to the health care professional, but directs anyone who deals with health care information. Sharing information to those without a specific purpose became a violation of federal law.

Judicial law, also known as case law or common law, is the ruling of a judge or judges. No matter how specific a legislative law may seem, applying the law can result in scenarios that do not have a clear determination. A judge or judges weigh the constitutional, legislative, and other case law against the facts of the scenario presented to the court. A jury may or may not be involved in reaching the verdict or decision for the case. The court’s ruling determines how that law applies to the scenario and becomes case law or precedent for future interpretation of such a situation; therefore, a practice violation could become a court case with a court determining if a violation occurred and corresponding penalties. Civil cases result in monetary damages as penalties. Criminal cases result in monetary damages and/or imprisonment.

Various categories of law exist that encompass aspects of judicial, legislative, and constitutional law, such as contract law, labor law, criminal law, civil law, and family law. Nursing practice focuses on two of the categories: criminal law and civil law. Criminal law involves laws, usually from legislative statutes, designed to punish those who endanger, threaten, or harm the health and safety of others or their property. The criminal laws are created to protect individuals, communities, and society. The penalty may be death, imprisonment, a fine, or a combination of the latter two. Criminal laws and nursing practice intersect in the areas of violence or abuse, illegal drug use, and intentional harm.

Civil law, also known as tort law, is an action against an individual or group causing damage that requires compensation or restitution to restore the person(s) to his/her/their state before the damage. The three classifications of civil laws are negligence, intentional torts, and strict liability, usually product liability. All three classifications influence nursing practice. For example, a defective infusion pump requires nursing actions to notify others through various reporting routes, including providing information for the institution’s report to the FDA. Preservation of facts and equipment surrounding the pump difficulties and accurate, factual documentation is imperative for determination of product liability in a situation of a potential manufacturer defect. The nurse is responsible for learning the organization’s procedure for collecting this information. Some institutions have an identified person, such as a paralegal in risk management, who maintains the forms, records, and evidence for the reporting process to the FDA and manufacturer. In other institutions, the process may be through the purchasing department or quality improvement department. The important issue is the removal of a potentially harmful piece of equipment from patient care and reporting it according to the organizational policy and procedure. Some organizations have references to FDA resources as part of the written process.

The topic of intentional torts is topical in all prelicensure programs. For example, nursing programs discuss how to avoid false imprisonment of a patient; however, the real-world application can be challenging in the heat of the moment. If a patient wishes to leave without a discharge order, the nurse may be inclined to say, “You can’t leave,” or “If you go, your insurance company won’t pay your bill,” or “You must sign this paper or I cannot let you go;” however, none of those statements are necessarily true. The nurse is liable for falsely imprisoning the patient who felt a threat to his or her autonomy to leave. Conversely, there are times when a patient can be held without violating the patient’s autonomy, such as when the patient is a danger to self or others. Autonomy and informed consent laws were fashioned from common (judicial) law cases in which the patients lacked information of possible outcomes before a procedure. Undergoing anesthesia, but awakening to an unexpected hysterectomy is a violation of one’s autonomy or ownership of one’s body. Generally, the person conducting an invasive procedure is required to inform the patient of the risks, benefits, and alternatives to treatment. Usually, evidence of informed consent is given when the patient or surrogate signs a consent form, indicating that the patient is freely giving his or her body or autonomy for the procedure. A nurse may witness the patient’s signature on the consent, yet does not hold the responsibility to inform a patient of the risks, benefits, and alternative treatments for a procedure performed by another. The practitioner performing the procedure holds the liability to follow professional and statutory standards for informed consent.

Negligence, however, strikes fear in the hearts of many from the beginning. When someone’s carelessness causes harm, the act is negligence. Malpractice is the term used when negligence occurs by a professional. Nursing is a caring profession, so the idea that one would harm a patient is abhorrent. Harming a patient because the nurse did something wrong often relates to negligence. Negligence involves several factors or elements: duty, breach of duty, injury or harm, and damages (see Figure 4.3). Nurses have a duty of care to the patient. When the nurse makes a mistake or omission in care (i.e., breach of duty), the patient experiences harm. The patient can choose to sue the nurse and others for the harm. A court may award monetary damages to restore the patient. Of course, this of is a very simplified explanation. One experiences shock and grief from harming the patient and from the court experience itself. The financial burden can be even more devastating if the nurse does not carry malpractice insurance.

Figure 4.3

Elements of Negligence

Laws also protect the nursing practice. Many acts performed as part of the nursing practice have penalties for those who pose as nurses without educational preparation, competency, and licensure. Other statutes and cases protect nurses’ right to identify credentials such as “RN” to patients, on name badges for example. This protects the profession and the public from those who portray themselves as nurses but are not. Also, protection exists for aid given in emergencies outside of the work setting, commonly referred to as Good Samaritan Laws. Good Samaritan Law is based on the biblical parable of a Samaritan who provided roadside aid to an assault victim who had been ignored by two previous travelers (Luke 10:23-37). The rescuer showed kindness and mercy, even though the Jewish victim likely would have shown contempt for any Samaritan. If a health care professional finds someone unresponsive on the street, is the duty of care to begin resuscitation measures an ethical one or a legal one? Is the professional’s choice swayed by the age or probable cause of the event, such as witnessing the cardiac arrest of a frail, older person or a known opioid overdose respiratory arrest in an emaciated young adult? In the parable, the biases of the previous travelers hindered them from providing aid to the assault victim. In most states, there is not a legal duty for the passerby. The term Good Samaritan Law invokes a sense of security that one may respond to emergencies without fear of legal reprisal. The law fosters quick response to emergencies for the good of the public; however, that protection extends only if one performs within the scope and standards of practice and without negligence or misconduct. The limits of Good Samaritan Law protections can serve as an incentive for understanding the scope of practice and standards of practice.

The previous content is a foundation for the subsequent sections of this chapter. Safety and quality have ethical, legal, and moral implications that require the use of critical thinking and clinical judgment. Health promotion is a logical outcome of the same. Nursing leadership opportunities arise in the ever-changing health care scene. Understanding and awareness of the role is foundational and yields an increasingly knowledgeable nurse who is prepared for the challenges.

Scope of Practice and Standards of Practice

Scope of practice and standards of practice tend to be used interchangeably. The terms imply a means of regulation and accountability for the practice of nursing (see Table 4.5).

Table 4.5

Differentiation between Scope of Practice and Standards of Practice

Scope of Practice	Standards of Practice
Extent of practice; practice boundaries	Minimum standard for proficiency and competence; also known as standards of care
Professional practice activities defined under state law (i.e., Nurse Practice Acts and rules and regulations). Some states have specific sections or resources noted for that state’s scope of practice	Professional practice activities defined under state law (i.e., Nurse Practice Acts and rules)
Specialty organizations publish relevant documents to define the scope further for that area	Define quality of care; provide specific criteria for the determination of quality of care
“The ‘who,’ ‘what,’ ‘where,’ ‘when,’ ‘why,’ and ‘how’ of nursing practice” (ANA, 2010a, p. 13)	Provision of practice activities in a consistent manner, meaning that another nurse with similar education and experience would provide care in a similar fashion

Scopes and standards in conjunction with codes of ethics are foundational to registered and advance practice nurses. From the first nursing course of a prelicensure program and forward, nursing students learn to practice within the boundaries of the nursing role and complete actions within the standards of nursing practice. A challenge in the initial nursing course is refuting the myths about what a nurse can and cannot do. Some students come to the program with a previous role in a health care setting, such as a pharmacy technician or patient care assistant. Accompanying the experience were positive and negative role models, and thus various perceptions of the nurse’s role. Others come with the perspectives formed by exposure to the various printed or electronic media versions or other fictitious characterizations of the role. The nursing student must push aside the preconceived perceptions of the role and embrace the true scope or boundaries. Students entering an advanced program such as the RN-BSN program at GCU have had some time gaining experience at the bedside. With experience comes the understanding of how these standards are applied and why the scope of practice is so imperative to patient care. Baccalaureate prepared nurses gain a greater understanding of the standards and scope, enabling them to coach and assist novice nurses in understanding their importance (see Figure 4.4).

Figure 4.4

Determinants of Nursing Practice

The scope of practice provides the freedom to apply educated critical thinking and skills into the provision of care within defined parameters. The parameters protect the public and the profession. Steps toward understanding and demonstrating the profession’s freedoms and the constraints begin with a nursing program education, progress to licensure, and continue with ongoing, lifelong learning. Obtaining licensure is not an easy undertaking. By the time of licensure examination, the candidate has the basic understanding of what actions are permissible within the role. Nevertheless, the person may or may not have read the Nurse Practice Act of the state in which he or she is practicing, relying only on educational exposure to the role.

Scenario

Before arriving, an anesthesiologist expects that the catheterization lab nurses will have obtained and administered a preprocedural medication even though he had not provided them with an order. While it may seem obvious that the response to this is, “I cannot do that without an order,” nurses habitually override the medication vending system and administer the medication because everyone gets the medication and the anesthesiologist eventually writes an order. This is wrong! The nurses are acting beyond the scope of practice for nonadvanced practice nurses. The act of obtaining and administrating the medication without an order is prescribing and not within the practice boundaries.

Nurse Practice Acts

Each Nurse Practice Act is the state-specific statutes addressing the scope and standard of practice; thus, Nurse Practice Act content varies from state to state. The statutes commonly require standards for nursing educational programs, types of and requirements for nursing licenses, and grounds for disciplinary actions. Some states, such as Ohio, subtitle specific sections delineating the scope from standards of practice. Each state’s Nurse Practice Act creates and empowers a board of nursing, which further refines the statutes through the development of administrative rules, known as rules or rules and regulations (see Table 4.6). The rules, once adopted, have the strength and effect of state law.

Table 4.6

Differentiation Between Nurse Practice Act and Rules

Nurse Practice Act	Rules
Laws/Statutes determined by the state legislature through the lawmaking process	Rules and regulations developed by the board of nursing and adopted through the board or state process; have the power and effect of law
Specify the requirements for safe nursing practice within the state	Stipulate the plan for safe nursing practice within the state
Identify the role of nurses, along with the scope and standards of care required for practice of nursing within the state	Refine the scope and standards of care required for practice of nursing within the state
Prescribe the need for continuing education and licensure renewal	Set standards for continuing education programs and license renewal
Creates the state board of nursing, the board membership, funding, and powers, including police and disciplinary powers	Guide board enforcement of the Nurse Practice Act/rules and implementation of disciplinary due process with remediation or penalties
Requires safe delegation of nursing care	Specify responsibilities within the practice, such as how effective, safe delegation occurs

Each board of nursing has police powerto protect the public from harmful nursing practice. The board’s primary objective is to serve the public, not nurses. Each nurse must guard against practices that would put patients at risk and report to the board any violations others have committed. At-risk behaviors for nurses include legal or illegal drug impairment while in the work setting, drug diversion and theft, theft from a patient, physical or sexual abuse of a patient, emotional abuse or boundary crossing of a patient, falsifying documents, and other criminal conduct. Generally, each health care institution has an internal chain of command for this reporting process. The nurse witnessing the situation should report within the institutional guidelines. Furthermore, the nurse is legally obligated to report unsafe nursing behaviors to the state’s board of nursing. Each board has a process for investigating allegations of unsafe practices. If the allegations are a violation, the involved nurse receives a hearing in which the nurse may present a defense. Nurse Practice Acts and corresponding rules and regulations specify how the due process proceeds. Disciplinary actions can be fines, temporary suspension of licensure, permanent suspension of licensure, and/or practice restrictions, such as being banned from administrating narcotics. Disciplinary actions are public record for public awareness and protection.

The state board of nursing is the owner of a nurse’s license, not the nurse. A nurse facing allegations of misconduct in a board of nursing investigation must respond promptly and cooperate with the board. Sometimes, such as cases involving impairment in which patient medication was not diverted, the involved nurse has the option of a voluntary temporary surrender of licensure while seeking help through a rehabilitation program. Usually, the nurse must seek out this option and promptly comply with time indicators for the process. Successful completion of the rehabilitation program includes counseling, abstinence, and monitoring. While frightening to surrender a hard-earned license voluntarily, success earns a return of licensure without a permanent notation on the nurse’s public record. Electronic records have made licensure records more easily available. Rapid licensure confirmation reports are available on state websites and through Nursys national data bank via the National Council of State Boards of Nursing (NCSBN) website. In the interest of protecting the public, information about licensure status, state board disciplinary actions, and practice privileges or restrictions are available to the public.

Malpractice

Nursing malpractice claims are on the rise according to a leading insurance carrier (Brown, 2016). Nurses should be concerned about malpractice litigation (Brown, 2016; Cooper, 2016; Sweeney, LeMahieu, & Fryer, 2017; Watson, 2014). The Medicare and Medicaid Patient and Program Protection Act of 1987 lead to the creation of the National Practitioner Data Bank (NPDB) under the U.S. Department of Health and Human Services. Since September 1990, the NPDB has stored reports regarding medical malpractice payments and adverse actions by health care practitioners, providers, and suppliers, including adverse licensure issues. Adverse action taken by a state board of nursing is reportable to the NPBD, and the report is electronically accessible to hospitals, plaintiff attorneys, other state boards of nursing, and other eligible parties, but not the public (National Council of State Boards of Nursing, n.d.). Sweeney, LeMahieu, and Fryer (2017) suggested malpractice data be analyzed and used to address areas of clinical weakness and improve quality of care and patient safety. Nurses must stay vigilant and safeguard themselves and others from acting negligently.

Not all nurses carry professional liability (malpractice) insurance, but should. Some mistakenly believe that an employer’s liability coverage is sufficient. Others believe the myth that if they hold a personal policy, they are more apt to be named in a lawsuit, believing the patient’s attorney seeks this individual source for payment of damages. Holding a personal policy has certain benefits. Employer coverage only extends to events occurring during the time of employment and on work time. Nurses are nurses 24/7. As health information and caregiving resources to the public, nurses do not limit actions to a setting. A nurse is liable at any time for perceived harm occurring in the workplace and nonworkplace settings. Lawsuits happen whether or not an error occurred. Also, a nurse does not always have the same perspective as the employer when an adverse event or lawsuit occurs. Sometimes, nurses act outside of the employer’s scope and standard of practice for the nurse’s position. This makes for a potentially adversarial relationship with the employer, and the nurse would benefit from the protection of his or her interests by the separate legal representation provided by the personal liability policy. The cost of a professional liability policy is minimal compared to the high cost of legal counsel and defense. Other benefits may be included that are not usually in employer policies, such as licensure protection benefits (Pohlman, 2015).

Check for Understanding

A surgeon orders, “Remove the g-tube.” The seasoned nurse, who has never removed one, enters the patient’s room, instructs the patient of the intent to remove the tube per the surgeon’s order, removes a skin suture, deflates the tube’s balloon, proficiently removes the tube, and documents the procedure with no harm to the patient. The Nurse Practice Act and regulations of the state say nothing about gastrostomy tube removal. The nurse knows nothing about practice and g-tube removal from specialty organization’s publications. The institution did not include the removal of gastrostomy tubes as a permissible procedure within the nurse’s scope of practice and practice standards or in the policy and procedure resource for the nurse’s guidance.

1. Did the nurse practice beyond the scope of practice?
2. If the nurse did not practice within the institution’s guidelines, will the nurse be directly liable for any harm? Will the institution not be held liable?
3. What should the nurse have done to avoid a practice issue?

Influences of Standards of Practice

Nursing programs endorse the concept of lifelong learning. Upon licensure, one cannot cease to think critically about the legal and organizational dynamics of the art and science of the nursing practice. Both the scope and standards of practice aim for prudent or sensible nurse behaviors. In other words, the aim is that one nurse’s thinking, behaviors, and direct actions would be like those of a different nurse with similar education in a similar situation. The nurse’s situation and experience are factors for consideration regarding what decisions and actions the nurse should determine after applying critical thinking; however, the core objectives are safety and the delivery of quality of care for the patient. Practices change over time, and technology is a rapidly changing influence that is shifting parameters. The public, including the legal systems, rely on the scope of practice and standards of care published by nursing specialty organizations. Health care organizations review and revise approved procedures for care within the boundaries of the system. Diligent attention to announced publications and revisions in the law, specialty practice, and organizational systems provides a dynamic platform for informed nursing delivery of care.

Institute of Medicine (IOM)

TheInstitute of Medicine (IOM), a nonprofit organization affiliated with the National Academies of Science, has become a major force for making the public aware of health care errors. In 1999, national media shared the IOM’s examination of problems within the United States’ health care systems. The report, To Err is Human, resulted in stories in national news media describing the tens of thousands of hospital deaths that occur annually from preventable medical errors. The report suggested a national focus on health care safety (IOM, 1999). Public outcry at the epidemic of preventable errors and demands for change spawned congressional hearings; accrediting organizations, insurers, professional groups, and others scrambled to define fatal and nonfatal events, develop reporting systems, and create strategies for nationwide change, such as raising performance standards. In 2001, the IOM’s report, Crossing the Quality Chasm: A New Health System for the 21st Century, modified the focus on errors and safety to a focus on quality as a means of safety and error prevention. Emphasis became safe, effective, timely, efficient, equitable, and patient-centered provision of care. Strategies incorporate customization of care based on an individual’s needs, continuous healing care, patient control over health care decisions, evidence-based practice, free flow of clinical information, and transparency (IOM, 2001; Wolfe, 2001). Soon health care jargon reflected these strategies. This focus persists through subsequent IOM publications, namely 2003’s The Future of the Public’s Health in the 21st Century and 2011’s The Future of Nursing: Leading Change, Advancing Health. The IOM reports reflect evidence that education level of nurses affects health care delivery and outcomes in terms of morbidity, medication error reduction, and length of stay (IOM, 2003; IOM. 2011). Professional organizations and accreditation bodies have urged skill mixes that reflect an increase of educational preparation of bedside nurses and the profession in general. The goal is that 80% of bedside staff will have earned a baccalaureate degree or an 80/20 skill mix of staff. Some health care organizations will not hire a nurse holding only an associate’s degree unless the nurse commits in writing to earn a baccalaureate degree, usually within 3 to 5 years. The health care organizations extend this expectation to nursing management with an expectation of obtaining a master’s degree or more advanced degree within 3 years of being hired.

Health promotion is a logical accumulation of safety and quality care efforts. Nurses understand that health improvements require advocacy for the public, opportunities for education of self and others, and removal of barriers to change. Several events are empowering nurses as leaders of health promotion, leadership, and advocacy, including the 2010 Affordable Care Act (ACA), the release of the IOM report, The Future of Nursing: Leading Change, Advancing Health, and the formation of The Future of Nursing: Campaign for Action. The latter two are presented here as part of the influence on nonprofit organizations on nursing and health.

The Future of Nursing: Leading Change, Advancing Health

With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. (IOM, 2011, p. 1)

The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) noted nurses’ commitment to improving care. The report declared that the nursing profession needs a transformation in the areas of practice, education, and leadership to improve health and care in the future. The IOM committee distinguished four key messages to guide the transformation:

1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States
4. Effective workforce planning and policy making require better data collection and improved information infrastructure (IOM, 2011, p. 4).

The report included eight recommendations for accomplishing the four key messages (see Table 4.7).

Table 4.7

The Future of Nursing Recommendations

Ethical Principle	Concepts/Duties
Recommendation 1: Remove scope-of-practice barriers.	Advanced practice registered nurses should be able to practice to the full extent of their education and training.
Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.	Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices.
Recommendation 3: Implement nurse residency programs.	State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.
Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.	Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.
Recommendation 5: Double the number of nurses with a doctorate by 2020.	Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.
Recommendation 6: Ensure that nurses engage in lifelong learning.	Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.
Recommendation 7: Prepare and enable nurses to lead change to advance health.	Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses.
Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data.	The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

Note. Adapted from The Future of Nursing, Leading Change Advancing Health, by the Institute of Medicine, 2011. Copyright 2011 by the National Academy of Sciences.

The IOM, more recently known as the National Academy of Science, Engineering, and Medicine, is a highly respected institute. By making recommendations to remove many practice barriers in nursing, the IOM provided powerful credibility to the need for changes in nursing roles. Many in the nursing profession had already been trying to remove the barriers, but now the IOM’s spotlight made others take notice, increasing the power to advocate for revisions. Recognition that nurses with a baccalaureate education and higher result in fewer patient errors and deaths spurred a new demand for nurses with advanced education. The focus is changing from skills to outcomes, health promotion, and preventative care at the community, state, and national levels. Doors have opened for new roles in nursing, especially for advanced practice nurses. Recognition of how nurses tie the components of health care together is increasing. More institutions are implementing the role of nurse navigator or transitional care coordinator to help guide the patient and families as they traverse the various aspects of clinical care. These nurses weave the dimensions of health care into a clear picture of the path toward the best patient outcomes that include more education, less stress, and less burden of cost.

The Future of Nursing: Campaign for Action

TheFuture of Nursing: Campaign for Action (also known as the Campaign for Action) is a response to the 2010 IOM report and is dedicated to implementing the report’s recommendations. Never has a project formed to address the public’s increasing demand for care “by utilizing all skills, talents, knowledge and experiences of nurses” (Future of Nursing: Campaign for Action, 2011, p. 1). It is helpful for nurses to understand which public organizations support the movement and professional group activities

The American Association of Retired Persons (AARP) is the largest nonprofit organization representing persons ages 50 and older. The Robert Woods Johnson Foundation (RWJF), the largest health-focused philanthropy group in the United States, partnered on the 2010 IOM report that studied nursing’s role in transforming health care (Campaign for Action, n.d.a). The American Association of Retired Persons (AARP) and the RWJF joined forces to promote the Center to Champion Nursing in America (CCNA). After the IOM 2010 report was published, the CCNA developed The Future of Nursing: Campaign for Action with the goal of improving the nation’s health through nursing. “The Campaign’s work is focused on the following issue areas: improving access to care, interprofessional collaboration, nursing leadership, nursing education, nursing workforce data, diversity in nursing, and building healthier communities” (Robert Woods Johnson Foundation [RWJF], n.d. para 2). The Campaign for Action notes, “America’s 3.6 million registered nurses are key to promoting health and creating communities in which everyone has access to high-quality care” (Campaign for Action, n.d.c, para. 2).

RWJF provides grants for organizations improving the health of the nation and funds many of the campaign’s project activities. Each state and Washington, D.C. has action coalitions composed of advocates from nursing, businesses, health care organizations, and interested consumers to accomplish the work of the campaign at the local, regional, and state levels. The coalition has liaison representatives to the national campaign and activities posted on the national website (Campaign for Action, n.d.b). State action coalitions are seeking nurses from every level of nursing to serve as advocates for the profession, health care, and positive health outcomes. Nurses and diverse stakeholders for any state coalition meet to address specific nursing profession issues and work to create innovative solutions with nurses leading the way. The opportunity to lead the way is empowering for the profession. Moreover, having a voice in an open forum helps nurses take action to generate positive opportunities for growth in the profession, rather than passively waiting for change. For example, Ohio has subgroups generating plans and achievements such as increasing the number of BSN-prepared nurses in the workforce, leadership and advanced education, residency programs (transition to practice), scope of practice/nurses practicing to fullest extent of their license, data (research), and diversity (Ohio Action Commission, 2017).

The Joint Commission (TJC) and National Patient Safety Goals

TJC Vision

One way of assessing quality measures of an organization is through accreditation. To reduce bias, this assessment process occurs from independent, nonprofit resources. Probably the most noted among such resources is The Joint Commission (TJC), an organization for accreditation of health care organizations and programs. Founded in 1951 as The Joint Commission on Accreditation of Healthcare Organizations (JACHO), TJC’s mission is to “improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (The Joint Commission [TJC], 2018a). TJC’s vision is that “All people always experience the safest, highest quality, best-value health care across all settings” (TJC, 2018a). Onsite assessments or site visits of health care organizations occur a minimum of every 39 months to determine whether health care organizations or programs are meeting TJC performance standards (TJC, 2018b). The site visits, known as surveys, are unannounced. Laboratory surveys are every two years (TJC, 2018b). Loss of accreditation or poor accreditation reports are warnings for the public. In addition, poor results can be financially devastating to the organization with fines and loss of insurance payers for services, Medicare payment in particular. TJC accreditation is voluntary and benefits health care organizations and programs as a sign of quality to both the public and the professions.

National Patient Safety Goals (NPSGs)

During this century, TJC established a program to address specific concerns regarding patient safety and publish annual National Patient Safety Goals (NPSGs). The goals are kept current through consultation with an appointed panel of experts known as the Patient Safety Advisory Group. TJC, with advisement from the Patient Safety Advisory Group, determines prioritization of and how best to address the NPSG (TJC, 2017c). NPSGs have influenced safety and quality practices, such as correct patient identification, improved staff communication, safer medication administration, infection prevention, avoidance of confusing medical abbreviations, better equipment alarms, and measures to prevent surgical or procedural errors, including surgery at a wrong site or wrong patient.

Red Rules

Red rules is a term developed by non-health care industries to indicate safety rules that should never be broken, for example, taking steps to identify patients in every instance prior to commencing care. Health care organizations have adopted this premise along with the concept, a culture of safety. A culture of safety promotes attitudes, beliefs, perceptions, and values that an organization and its employees share to promote safety in the workplace. The red rules and culture of safety create a standard for care in which all, including associated physicians, adhere to measures for avoidance of error. Media exposure and the IOM 1999 report became the incentive to push for a culture of safety. Health care organizations urgently wished to avoid further patient safety events or sentinel events. TJC (2017b) terms an event not primarily related to the natural course of the patient’s illness or underlying condition apatient safety event. If a patient safety event results in death, permanent harm, or severe temporary harm and intervention required to sustain life, then the event becomes a sentinel event. TJC requires health care organizations to conduct a specific investigation, known as a root cause analysis (RCA), of every sentinel event. The RCA detects flaws in the caregiving system that failed to provide safety nets against patient harm. Such analyses have revealed points at which actions taken could avert harm and change the outcome. For example, at multiple points, a change in action could avoid the harm in cases of surgery on the wrong extremity, mishandling of laboratory specimens, surgery on the wrong person, instruments left in the body after surgery, and so on. Now commonplace, red rules include timeouts prior to any procedure, two forms of patient identification prior to any delivery of care, and bedside labeling for every patient specimen. Understanding RCA processes, in advance of patient safety events, helps a nurse be more safety conscious, prepared for beneficial documentation, and better equipped with information during the organization’s data gathering and interviewing process. TJC provided resources for understanding the process and expectations of a RCA (Parker, 2015).

Just culture, a safety culture concept, focuses on system issues that result in unsafe behaviors, yet holds individual employees accountable for avoiding reckless or risky behaviors and human error (Ulrich, 2017). As humans, nurses sometimes unknowingly make an error. Risky or at-risk behaviors are actions increasing the risk of error, such as taking a shortcut. The nurse accepts the risk, believing the risk is justified or that the outcome will be unaltered, yet error or a near miss may occur. Unfortunately, errors or near misses also occur when the person recklessly and deliberately chooses to ignore the scope of practice, practice standards, policies, and normal procedures. According to TJC (2017a), clear lines should be “drawn between human error and at-risk or reckless behaviors” (p. 2). In a 2010 position statement, the ANA indicates that a just culture does not assign personal blame for every error and does not hold persons singularly accountable for failures in the system (ANA, 2010b). Analysis of errors or near misses in just cultures includes the type of behavior associated with the error. The concept encourages employees to report all errors, near misses, and system difficulties, without fear of unfair blame and with the confidence of fair employer treatment (Paradiso & Sweeney, 2017). Awareness and analyses of the errors, near misses, and system difficulties allows the health care setting an opportunity to make changes that create safer, quality care environments for patients, families, and the organization.

Check for Understanding

1. What is the process in your workplace if you believe a sentinel event has occurred?
2. What barriers do you perceive to reporting a sentinel event in your workplace?
3. What support for reporting errors exists where you work?

Federal Legislation Influencing Health Care

Health and Insurance Portability and Accountability Act of 1996 (HIPAA)

In the 1990s, issues about access to personal medical information reached a national concern, especially because of the increasing use of technology, increased research, and personal information risks resulting from discoveries of genomic processes. The Health Insurance Portability and Accountability Act (HIPAA) established changes in the insurance industry, but especially important to nursing, created a law to be used in all health care settings holding personal medical information. Confidentiality, an ethical expectation, was now a federal law with guidelines for storing, accessing, and releasing personal health care information as “protected health information” whether the information is oral, written, or electronic. Individuals have protection from release of information that had personal identifiers. HIPAA Privacy and Security Rules developed as administrative regulations governing the protection of health information with disciplinary processes for violations. The threat of sanctions for violations of HIPAA was soon tested. In a landmark settlement, the U.S. government received $2.25 million from CVS Caremark Corporation for violating HIPAA privacy rules, such as patient information disposed in open dumpsters along with insurance information (Federal Trade Commission, 2009; U. S. Department of Health & Human Services, 2009).

The final modification to these privacy and security rules occurred in 2013. The final modification included expansion of the right of individuals to receive electronic copies of their health information and placed restrictions against disclosure to health plans for out of pocket treatments paid in full by the individual (Allen, 2013). The Genetic Nondiscrimination Act (GINA) prohibits health insurance plans from using or disclosing genetic information in determining coverage. The final 2013 modification of HIPAA applies GINA to those who fall under HIPAA rules (Allen, 2013).

Nurses can avoid HIPAA privacy violations by following some basic professional guidelines:

• Stop gossiping or face a serious fine. Do not share information with coworkers not related to the patient’s care. Sharing patient information should not occur with friends, family, and acquaintances.
• Be aware of location when speaking or whispering about a patient situation including hallways, cafeterias, and elevators. If answering a unit communication in another patient’s room, halt the conversation until in a secure area.
• Keep written information, such as charts, personal notations, or assignment sheets out of public view. Shred documents when finished.
• Use strong password protection and encryption of electronic and mobile devices that house patient information. Report lost and stolen devices promptly. Remember theft of protected health information from a stolen device can result in fines.
• Resist accessing patient information when not authorized as a caregiver.
• Do not mingle work and social media or text patient information. If working from home, keep screens out of view of family and friends and lock the computer when stepping away.
• Release information only with written authorization by the patient or legal guardian.

Remember, violations have consequences through the U.S. Department of Justice. The lowest penalty for knowingly obtaining and disclosing information comes with fines up to $50,000 and up to 1 year in prison (U. S. Department of Health & Human Services, 2013). The patient could file a civil suit as well. Consequences for violations involving wrongful conduct, false pretenses, selling or transferring identifiable health information, or malicious intent are higher with 5 to 10 years in prison and fines of $100,000 to $250,000 depending on the violation (U. S. Department of Health & Human Services, 2013). A violation can involve multiple parties (Cannon & Caldwell, 2016).

Affordable Care Act (ACA)

The controversial Patient Protection and Affordable Care Act (PPACA) is often abbreviated as the ACA. President Barack Obama signed the ACA into law in 2010, and the U.S. Supreme Court upheld the law as constitutional in 2012 (Deparle, 2012; Oberlander, 2012). The ACA featured provisions for health insurance and health system reform (U. S. Department of Health & Human Services, 2013). Insurance reform provisions targeted insurance coverage for more Americans, more insurance benefits and protections, and lower insurance costs for consumers and the government (American Public Health Association [APHA], 2012). Uninsured Americans would now have a pathway for affording health insurance. By March 2015, an estimated “16.4 million uninsured people had gained health insurance coverage as several of the Affordable Care Act’s coverage provisions took effect” (Office of the Assistant Secretary for Planning and Evaluation, 2015, p. 1).

Provisions to reform the health system pursued improved quality and effect, stronger workforce and health care infrastructure, and a greater focus on public health and prevention (APHA, 2012). Thus, the ACA turned health care upside down (see Figure 4.5). Health care formerly focused on providing care, but now the focus is managing health (Berg & Dickow, 2014). The change created a transformation in health care.

Figure 4.5

Transforming Health Care

Note. Adapted from “Nurse Role Exploration Project: The Affordable Care Act and New Nursing Roles,” by J. G. Berg and M. Dickow, 2014, Nurse Leader, 12, 40-44. Copyright 2014 by Nurse Leader.

According to Berg and Dickow (2014),

The emphasis on wellness and primary care in the transformed system under the ACA also promotes a definition of health that transcends the absence of disease to embrace social determinants of health, (including health behaviors such as tobacco use, diet, and exercise; social and economic factors such as education, income and family support; clinical care inclusive of access to care and quality; and the physical environment which considers things such as the quality of the air we breathe and the safety of our living conditions). (p. 41)

Specialty departments and services with isolation of information within the department usually drove health care before the ACA. After the ACA was implemented, health care now avoids siloed services, preferring instead patient-centered and outcome-driven, high-quality care. A care delivery model is known as an integrated practice unit (IPU) formed. Care structures around the medical condition with fully integrated care including treatment, education, counseling, and prevention. IPU achieves positive outcomes and lower expenses (Aoughsten, Johnson, Kuruvilla, & Bionat, 2015; Porter & Lee, 2013). Nurses have more opportunities for health promotion, leadership, and quality outcomes. For example, development or expansion of roles as nurse navigators, care coordinators, faculty team leaders, informatics specialists, community-centered nurses, and primary care partners (Berg & Dickow, 2014).

Availability of public information regarding the quality of health care increased with the transparency concepts of the ACA. The components of the ACA hold the government, health care providers, and health care organizations more accountable to deliver cost-efficient, quality care under this public scrutiny. The ACA includes multiple measures for health care quality, including the:

• National Quality Strategy (NQS) to lead all levels of government toward alignment with public and private payers for quality improvement strategies.
• Center for Quality Improvement and Safety to encourage evidence-based practice strategies for health care delivery.
• Patient-Centered Outcomes Research Institute (PCORI) enhancing informatics ability to generate patient-centered evidence for use in developing outcome measurements.
• Center for Medicare and Medicaid Innovation (CMMI) for inclusion of quality measurement and improvement in development and trials of new payment and delivery models.
• Physician Quality Reporting System (PQRS) for physician quality reporting of patient outcomes, perceptions, and timeliness of care, giving professionals an opportunity to evaluate performance. Those not participating are subject to reduced Medicare payment for services, known as a negative payment adjustment.
• Public Use Files (PFU) of state-based, competitive health insurance exchanges or marketplaces to provide a public report of the quality of health insurance plans.

Other features target health disparities by increasing data gathering on race, ethnicity, gender, socioeconomic status, and language. Having additional and better quality informatics regarding the diverse populations allows measures to reduce risks for health inequity. Culturally specific benefits directed to American Indians and Alaska Natives are an effort to reduce health inequities under the ACA. Authorization for new payment and care delivery models, focusing on quality, motivates new innovative approaches for health care organizations.

Under ACA mandates, health care providers must have a compliance program. Protection and prevention are primary goals of compliance programs. In health care, a provider’s formal program requires policies, procedures, and other internal processes designed to prevent and detect violations of federal and state laws. Preemptive and prompt detection of Medicare and other insurance fraud, waste, inefficiency, and abuse promotes safety for the health care organization, increases proper submission of claims, and reduces billing error. The compliance programs internalize promotion of patient safety and delivery of high-quality health care with more efficiency, less waste, and increased patient satisfaction. The nurse may participate in the formation of policies, procedures, and standards of conduct in an organization’s compliance program. The nurse demonstrates accountable and ethical behaviors, including cooperation with the compliance officer declared responsible for the program within the health care setting. Allegiance to the program policies may include whistleblowing on policy violations via reporting to a tip line or hotline. Nursing cooperation incorporates submission to education and training, prompt reporting of questionable practices, and responsiveness to the compliance officer’s investigations. Failure to respond and/or report can lead to disciplinary actions.

Human Subjects Research Protection

Autonomy, beneficence, and justice principles are at play when approaching potential participants and during the process of conducting research on human subjects. The federal government expects researchers to apply the highest ethical standards to protect any human subject (National Institute of Environmental Health Sciences, 2015; Domenech Rodríguez, Corralejo, Vouvalis, & Mirly, 2017). Congress passed legislation, effective January 2018, to update the federal law known as the Common Rule. Through mandates for ethical guidance and accountability, the Common Rule protects the rights, welfare, and well-being of human research participants. Nurses participating in research using human participants or biological specimens should familiarize themselves with the new law. Among the provisions adopted is a new rule requiring simpler informed consent forms to aid understanding for those who are trying to decide whether to participate as a research subject, as well as a reduction in the complexity of the information presented by placing key information in the beginning rather than buried within the consent form (Berkowitz, 2017; Menikoff, Kaneshiro, & Pritchard, 2017).

Health and Human Services and Information Technology (IT) Legislation

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act expanded the HIPAA Privacy and Security Rules. The act set goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes” (Gold & McLaughlin, 2016). The term meaningful use became the new jargon regarding the use of protected information. The aim was to increase electronic health record (EHR) adoptions for “more efficient, patient-centered health care system by lowering providers’ administrative costs, improving coordination of care among multiple providers, and increasing patients’ participation in and responsibility for their own care” (Galbraith, 2013, p.15). The U.S. Department of Health and Human Services’ goal was quality, safe EHR that were efficient to reduce health disparities, ease care coordination while maintaining privacy and security of patient health information. The Centers for Medicare & Medicaid Services implemented the “Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers” (Thurston, 2014, p. 510). Health care providers and organizations, if qualifying, received a financial incentive to transform the record creation and storing processes on an electronic basis. A key feature of the health information technology (HIT) was the interoperability of the EHR to maximize the use of EHRs as a tool for “efficient, effective, safe, and quality care” (Skiba, 2013, p. 356). A benefit for the public was increasing access to one’s health care record through secure electronic access. In addition, measures of the ACA reinforced the use of HIT and health information privacy requirements (U. S. Department of Health & Human Services, 2013).

Soon after the government established the Office of the National Coordinator for Health Information Technology in 2004, a grassroots nursing initiative began, now known as the TIGER initiative. The Technology Informatics Guiding Educational Reform (TIGER) Initiative focused on how to prepare nurses for the patient-focused HIT environment and created a Web-based learning platform for this purpose. The latter became the TIGER Virtual Learning Environment (VLE), which may be subscribed to by any health professional, faculty member, or student who wants “to learn and develop knowledge, skills, and awareness of technology and informatics” (Skiba, 2013, p. 356). Thus, nurse educators had a new resource for preparing nurses.

Taking Action and the World of Politics

What is the outlook for the professional nursing practice? Certainly, lifelong learning components urge the professional nurse to keep well informed of the Campaign for Nursing progress along with ongoing IOM reports, including progress toward increasing the number of BSN-prepared nurses. “The need for key stakeholders to provide leadership to take advantage of opportunities and overcome barriers has never been greater” (Berg & Dickow, 2014, p. 33). Leadership in the California Action Coalition urges nurses forward as “there is tremendous opportunity for nursing to lead important changes that are necessary to improve health for all residents in the state” (Berg & Dickow, 2014, p. 33). Involvement can be on the local, state, national, and global levels regarding emerging health care initiatives.

The world of politics is not one most nurses perceived as part of the job when entering a nursing program; however, health care requires increasing involvement from nurses on all political levels from the local to the global arenas. Nurse political participation could focus on a segment of the populations rather than a direct link to a health care setting. For example, Driscoll and Darcy (2015) studied legislation regulating adolescents’ use of tanning beds, noting no reduction in the rate of use. Along with educating patients and families, Driscoll and Darcy urge nursing activism “for legislation, enforcement of legislation, and public awareness of this global health issue. As advocates, nurses can have a direct impact upon the long-term goal of reducing the harmful effects of continued UVR exposure in this vulnerable population” (2015, p. 62).

Reflective Summary

Certainly, lifelong learning components urge the professional nurse to keep well informed of Campaign for Nursing progress along with ongoing IOM reports. All registered nurses are to become active players as barriers to nursing practice are removed, higher education is expected, and public demands for quality, safety, and health promotion increase. Nurses should incorporate the traits of critical thinking, clinical reasoning, and clinical judgment into all practice. Adherence to ethical principles, laws, scope and standards of practice, and safety goals are integral to safe and quality care. Laws are slow to change, but legislation shapes the current health care system. The nurse cannot sit on the sidelines of health care, but must act and incorporate political involvement into his or her practice.

Key Terms

Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into law by U.S. President Barack Obama and became known as Obamacare; among the provisions include health insurance coverage to uninsured, measures to lower costs and improve health care system efficiency, preventative care, extension of care to dependents under the age of 26, and prohibited insurance claim denial or higher premiums for preexisting conditions.

Analyticity: Utilization and application of evidence-based practice to perform patient care.

Applied Ethics: Various approaches to ethical dilemmas.

Autonomy: Free will to make own decisions about self and physical body.

Beneficence: Actively helping, doing kindness, performing quality conduct, and sharing goodness for the benefit of others.

Campaign for Action: Collaborative effort to implement the recommendations on nursing from the 2010 Institute of Medicine’s report The Future of Nursing: Leading Change, Transforming Health.

Clinical Judgment: “The outcomes of critical thinking in nursing practice. Clinical judgments begin with an end in mind. Judgments are about evidence, meaning and outcomes achieved” (AACN, 2008, p. v).

Clinical Reasoning: “The process used to assimilate information, analyze data, and make decisions regarding patient care” (AACN, 2008, p. v).

Confidence: Trust in one’s own capabilities.

Confidentiality: Keeping information secret from others; not disclosing private matters.

Compliance Program: Supervisory program to keep health care decision-making processes free of unethical influences and actions, identify fraud and abuse risks, promote adherence to laws, and require disclosure of accurate pricing information and truth in advertising.

Critical Thinking: “All or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity. Critical thinking underlies independent and interdependent decision making” (AACN, 2008, p. v).

Culture of Safety: Attitudes, beliefs, perceptions, and values that an organization and its employees share to promote safety in the workplace; organization-wide recognition of the risks in day-to-day activities with a resolve that all will employ safe practices consistently.

Ethical: Concepts and beliefs regarding right, good, law-abiding, honest, and respectable behaviors; regarding moral values.

Ethical Dilemma: Situations in which a difficult choice is required among options, none of which will resolve the situation in the most favorable ethical manner; moral value predicament.

Ethical Principles: Fundamental truths or foundational ethical values, assumptions, and beliefs

Fidelity: Loyalty; faithfulness to promises and duties.

Good Samaritan Law: State legislative protection against malpractice for those who provide emergency assistance to an injured person, in good faith (sincerity) and with reasonable care.

Health Disparity: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages..

Health and Insurance Portability and Accountability Act of 1996 (HIPAA): Signed into law by U.S. President Bill Clinton granting workers the ability to continue receiving health insurance coverage when changing or losing employment and yielding security and privacy standards for handling of patient health care information, including electronic transmissions.

Inquisitiveness: Curiosity for facts; thirst for knowledge; asking questions and researching answers. The nurse continually seeks new solutions and knowledge related to the given problem.

Institute of Medicine (IOM): A nonprofit organization affiliated with the National Academies of Science.

International Council of Nurses (ICN): An organization bringing together more than 130 nurses associations from various nations to advocate for quality in professional practice, health policies, and respect of the profession.

Integrated Practice Unit (IPU): A jointly accountable, multidisciplinary grouping of health care providers and staff that is organized around an individual’s health condition, providing comprehensive care for the full cycle of the condition and surrounding circumstances, incorporating direct contact, education, electronic communication, and follow-up.

Just Culture: Safety culture concept focusing on system issues that result in unsafe behaviors, yet holds the individual employee accountable to avoid reckless or risky behaviors and human error. Error or near miss analysis are based on the type of behavior associated with the error and not the severity of the event.

Justice: Fairness; impartiality; treating others the same.

Liable: Responsible or legally accountable; can be sued.

Malpractice: Negligent, illegal, or unethical professional action or omission that results in harm.

Meaningful Use: Government standard regarding the electronic exchange of patient information among health care providers, insurers, and patients for enhanced efficiency, safety, quantity, and quality of information sharing.

Metaethics: The nature of ethics and moral reasoning: right vs. wrong; good vs. evil; normative ethics which is the ethics of right and wrong in human action, addressing what we ought to do.

National Patient Safety Goals (NPSGs): Goals determined by The Joint Commission (TJC) specifically to improve the safety of patients; promotes and enforces major changes in safety measures for the recipient of health care.

National Practitioner Data Bank (NPDB): An ongoing storehouse of reports regarding medical malpractice payments and adverse actions by health care practitioners, providers, and suppliers, including adverse licensure issues.

Near Miss: A narrowly avoided error.

Negligence: Careless or improper behavior that results in damage.

Nurse Navigator: Person guided by evidence-based practice who helps patients understand the health care system; coordinates and transitions patient care through the system and into other systems.

Nonmaleficence: Committing no harm or evil; based on Hippocrates’s admonishment to first do no harm.

Open-Mindedness: The ability to be tolerant of opposing views and consider other perspectives and proposals.

Patient Safety Event: An event not primarily related to the natural course of the patient’s illness or underlying condition.

Police Power: Authority granted to the states by the 10th Amendment of the U.S. Constitution, allowing enactment of restrictive measures to preserve and protect order, safety, health, welfare, and morals of the public.

Privacy: Ability to keep personal matters to oneself or ability to be alone when desired and away from critical observation by others.

Respect: Treating every person as a worthy individual; honoring autonomy and protection for those with diminished autonomy.

Root Cause Analysis (RCA): Comprehensive systematic analysis designed to detect flaws in the caregiving system that failed to provide safety nets against patient harm; analysis to find the basis or causal factor(s) that resulted in a variation of performance.

Sentinel Event: A patient safety event, not related to the natural course of the patient’s illness or underlying condition, which results in death, permanent harm, or severe temporary harm and intervention required to sustain life.

Siloed: Separate and isolated process, department, or system from others.

Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.

Statutes: Laws passed by a state or the federal legislature; formal regulation.

Systematicity: Organized work process and flow.

The Joint Commission (TJC): Independent, nonprofit organization that conducts reviews for health care organization accreditation or program certification. TJC accreditation and certification represents a symbol of quality.

Technology Informatics Guiding Educational Reform (TIGER) Initiative: Effort focused on the readiness of nurses for the health information technology environment (HIT); created a Web-based learning platform for nurses learning HIT.

Tort Law: Law dedicated to remedies for harm caused by the unreasonable action, carelessness, or omission by others.

Veracity: Accuracy, honesty, truthfulness.

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1. Summary of the article: Mankins, M, & Steele, R, 2005, Turning great strategy into great performance, Harvard Business Review, July-August, 2005.
2. An analytical summary of the main points

The article Turning Great Strategy into Great Performance addresses the problems that companies face in efforts to realize the full potential value of their strategies. The author points out that fail to realize this value because of breakdowns and defects at the planning and execution stages. The author highlights seven simple rules that companies can use to achieve more potential from their strategies, thereby filling in the so-called strategy-performance gap.

The first rule is on keeping the strategy simple while making it concrete (Mankins & Steele 2005, p. 69). In this regard, efforts should be made to avoid the tendency to work with strategies that are in essence highly abstract concepts (Hackman 2008, p. 8). The author notes that such abstract strategies are difficult to communicate or even translate into action. In other words, they do not lead to executable plans.

The second rule is that debates should be focused on assumptions and not forecasts. The author notes that in many companies, planning is largely a political process, whereby a negotiated settlement is reached on the strategic plan of the business as far as financial forecasts and performance targets are concerned. By focusing on assumptions instead of forecasts, the planning process becomes isolated from political concerns regarding performance evaluation, and biases on financial projections (Gadiesh 2001, p. 106; Vickery 1993, p. 455).

The third rule states that a rigorous framework should be used, and that everyone should speak a common language. The author indicates that this rigorous framework should be the basis on which dialogue should take place between the center of corporate operations and business units in order for productivity to be increased. This communication should be about assumptions and market trends (Neilson, Martin, & Powers 2001, p. 83).

The fourth rule emphasizes the need for resource deployments to be discussed early. By discussing the timing and level of the deployment of critical resources, more realistic forecasts are created. Moreover, more executable plans are put in place. The author gives the example of Cisco Systems, a company that deployed cross-functional teams to review the level of resource deployments as well as timing of these deployments during the planning stage.

In the fifth rule, the authors states that priorities should be clearly identified. To emphasize this point, the author states that for any strategy to be delivered successfully, managers need to make numerous tactical decisions and continually put them into action using a priority-based approach. The most successful companies are those that explicitly state their priorities so that each top executive knows clearly where he should first and foremost direct his efforts (Wong 2008, p. 389; Crittenden 2008, p. 303).

The sixth rule in the article is on continuous monitoring of performance. Through this monitoring, the top executives are able to determine when too many, too few, or just optimal-level resources are being channeled into the business to deliver the desired goods. It is emphasized that such monitoring is crucial industries where events that are outside any individual’s control can easily throw a plan into irrelevance.

The last rule stated in the article requires the managers to keep on rewarding and developing capabilities for execution. In other words, staffs need to be developed and motivated. Any process being undertaken is as good as the people who are entrusted with the task of ensuring that it works (Kaplan & Norton 2000, p. 52). This is particularly important with regard to efforts to select and develop the management team.

1. An explanation of what the key points mean to a manager in terms of how they would do their job.

These key points in the article have far-reaching implications on how managers would go about doing their job. First, managers would have to be assertive in the directions that they give to those working under them. They would have to learn to give directions that do not yield any form of ambiguity.

Secondly, the managers would have to make realistic assumptions and not forecasts. They would have to be realistic when giving performance targets, yet act in a way that enables them shun company politics. Moreover, the business leaders would have to get used to dialoguing all the time with different business units.

The managers’ work would also change in respect of the timing of discussions on resource deployments. The managers would have to be used to the practice of discussing resource deployment issues on time. Such a practice creates opportunities for resources to be deployed at the exact moment that they are needed.

Additionally, and quite importantly, the article would require the corporate chiefs to get used to making thousands of decisions. These decisions require a lot of prioritization when time for implementation comes. The managers would be required to have a clear picture of which actions to prioritize on.

2. Summaries of two academic journals directly related to the seminal topic
3. Oshri, I, Newell, S, & Pan, S, 2007, ‘Implementing component reuse strategy in complex products environments’, Communications of the ACM, 50, No. 12, pp. 63-67.

Oshri, Newell, & Pan (2007, p. 63) note that as tensions grow in the process of changing operating procedures, so do costs. In light of this realization, they set out to illustrate how the introduction of complementary initiatives can help ease friction between management and engineers. The core issues discussed fall in the realm of knowledge management (KM) practices.

Specifically, focus is on the hidden, unanticipated costs relating to knowledge management practices, particularly in the reuse of subassemblies and components (Oshri, Newell, & Pan 2007, p. 64). One of the ways in which these costs arise is through tensions between management and engineers. Using the case study approach, the authors demonstrate the need for companies to be alert to different unanticipated costs relating to KM practice as well as present various complementary initiatives aimed at counterbalancing this negative impact.

This article relates to the article set for the topic in that the issue of complex products environment resembles the environment in which organizational strategies are executed. In the article set for the topic, there is emphasis on continuous monitoring to ensure that resources are made available at the right time. Similarly, in this article, there is a lot of emphasis of monitoring unanticipated costs and ways of counterbalancing their negative effects.

580. Sarin, S, Challagalla, G, & Kohli, A, 2012, ‘Implementing Changes in Marketing Strategy: The Role of Perceived Outcome and Process-Oriented Supervisory Actions’, Journal of Marketing Research, 49, No. 8, pp. 564–580.

This article highlights the roles that supervisors should play in the implementation of strategies in a company’s marketing strategy. The authors argue that the way outcome-oriented actions of supervisors are perceived influences the primary appraisal that salespeople give regarding strategic change, particularly with regard to whether this change will affect them. Evidence in support of this argument was sought through a survey of 828 salespeople (Sarin, Challagalla & Kohli 2012, p. 565). The authors found out that the primary appraisal of the salespeople had an influence on their behavior towards change implementation.

This study is related to the article that is set for the topic because it addresses the issue of strategy. The article addresses the issue of perceptions of outcome-oriented actions of supervisors. Similarly, the article set for the topic addresses the need for strategy-related actions to be oriented towards executable plans and concrete outcomes.

References

Crittenden, V, 2008, ‘Building a capable organization: The eight levers of strategy implementation’, Business Horizons, Vol. 51, No. 4, pp. 301–309.

Gadiesh, O, 2001, Transforming Corner-Office Strategy into Frontline Action, Harvard Business Review, May 2001, pp. 101-119.

Hackman, R, 2008, Leading Teams: Setting the Stage for Great Performances, Harvard School Business Press, Boston.

Kaplan, R, & Norton, D, 2000, Having Trouble with Your Strategy? Then Map it, Harvard Business Review, September 2000, pp. 49-60.

Mankins, M, & Steele, R, 2005, Turning great strategy into great performance, Harvard Business Review, July-August, 2005.

Neilson, G, Martin, K, & Powers, E, 2001, The Secrets of Successful Strategy Execution, Harvard Business Review, May 2001, pp. 82-93.

Oshri, I, Newell, S, & Pan, S, 2007, ‘Implementing component reuse strategy in complex products environments’, Communications Of The ACM, Vol. 50, No. 12, pp. 63-67.

Sarin, S, Challagalla, G, & Kohli, A, 2012, ‘Implementing Changes in Marketing Strategy: The Role of Perceived Outcome and Process-Oriented Supervisory Actions’, Journal of Marketing Research, Vol. 49, No.  8, pp. 564–580.

Vickery, S, 1993, ‘Production Competence and Business Strategy: Do They Affect Business Performance?’ Decision Sciences, Vol. 24, No. 2, pp. 435–456.

Advancing Professional Standards By Sue Z. Green

Essential Questions

• How does the nurse adhere to and elevate standards or the profession?
• Which aspects of ethical principles and nursing standards are most evident in practice?
• What are the external factors that influence nursing standards?
• What are some of the most notable recent federal laws transforming healthcare?

Introduction

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work, and devote myself to the welfare of those committed to my care. (American Nurses Association [ANA], n.d.)

Nurses at pinning ceremonies often recite the Florence Nightingale Pledge. The recitation occurs at a time of excitement and relief as students graduate from a nursing program. The pledge represents the ethical principles of the profession, much as the Hippocratic Oath is for the medical profession. Nurses publicly announce a commitment to the avoidance of deleterious behavior (i.e., do no harm to themselves or patients) and devotion to confidentiality and welfare of those under their care. The pledge is a sign of dedication to ethical principles, professional accountability, and adherence to standards of practice. Perhaps, few recognize the true strength of this responsibility at the time of graduation. The loyalty to the profession calls nurses to have ongoing professional development and devotion to elevate the profession.

Nightingale, viewed as the founder of professional nursing, approached nursing care through the compilation of information regarding patient care. In other words, Nightingale is the true founder of data-driven, evidence-based nursing practice. Standards of care focused on clean air and the surrounding environment, along with nutrition and sleep. She documented statistical data to prove the standards saved lives and hastened recovery. Her diligence drove the development of standardization of practice evident today. In addition, Nightingale advocated for the ongoing development of nurses and adherence to ethical principles of practice.

Innumerable activities of nurses arise from the development of professional accountability, adherence to standards of practice, and ongoing professional development. These foundational aspects of nursing evolve from thinking abilities, acceptance of ethical principles, and understanding professional obligations. This chapter will explore these aspects, along with the interplay of scope and standards of practice. The impact of two nonprofit organizations—the Institute of Medicine and The Joint Commission—on quality, safety, and health promotion in health care is part of the content. Legislative actions resulting in dynamic health care changes are relevant materials, along with a projection to future changes.

Critical Thinking, Clinical Reasoning, and Clinical Judgment

Human brains grow and develop pathways for speech, thought, and logical analysis. Sciences studying these processes note differences in abilities over time and life experiences. Although people entering nursing have thinking abilities, nursing requires the development of additional ways of thinking: critical thinking, clinical reasoning, and clinical judgment. The ways of thinking begin in prelicensure education and grow with experience and ongoing professional development. One of the aspects of baccalaureate education is the emphasis on the ways of thinking.

Critical Thinking

Critical thinking in nursing is the ability to apply the nursing process effectively and purposefully to an identified problem. Since becoming a student, the nurse learns to apply logical and empirical reasoning when making important decisions regarding patient care. Much thought about assessment, analysis of information, determining desired outcomes, and planning occurs before interventions. Nursing experience and ongoing professional and academic development, such as baccalaureate education and beyond, increase the thought process involved. Many characteristics contribute to the development of a critical thinker including the following traits:

• Inquisitiveness—the nurse continually seeks new solutions and knowledge related to the given problem
• Systematicity—organized work process and flow
• Analyticity—utilization and application of evidence-based practice to perform patient care
• Open-mindedness—the ability to be tolerant of opposing views and consider other perspectives and proposals
• Confidence—trust in one’s own capabilities

These elements, taught and discussed in nursing programs, receive honing at the bedside through gained experiences (Gul & Boman, 2006). Systematicity enhances the nurse’s ability to put intuitiveness, analytical abilities, tolerance, and confidence into practice. Formal approaches to organized workflow arose from theories among other disciplines. For example, by studying general system’s theory, nurses observed the cause and effect nature of nursing actions on the patient outcomes. By applying scientific approach theories, nurses organized care based on the classic scientific methods of observation, hypothesis, experimentation, and corroboration (Humphris, 1979). With the passage of time, nurses advanced the profession by developing other theories of approach. Henderson built on Nightingale’s concepts to identify 14 basic human needs affecting patient recovery and independence, launching modern-day nursing approaches (Crossan & Robb, 1998; Dijkstra, Buist, & Dassen, 1998). The nursing process became prominent as the nurse’s systematic approach after the 1961 publication of Orlando’s The Dynamic Nurse-Patient Relationship, advocating the deliberative nursing process (Crossan & Robb, 1998; Faust, 2002; Kim, 1994; Potter & Brockenhauer, 2000; Potter & Tinker, 2000; Rosenthal, 1996).

No universal definition of critical thinking exists for the nursing profession. Use of the term is often interchangeable with the terms clinical judgment or clinical reasoning (Alfaro-LeFevre, 2017). The terms reflect nursing perceptiveness and position the nurse to use “clinical judgement as rational and directed only toward resolutions of problems and clearly defined ends” (Benner, Sutphen, Leonard, & Day, 2010, p. 200). The American Association of Colleges of Nursing’s (AACN) publication, The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008), distinguishes the three terms (see Table 4.1). AACN (2008)denotes critical thinking as a decision-making process involving “questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity” (p. v). Clinical reasoning extends the process to integrate and analyze information and make decisions about patient care (AACN, 2008). Clinical judgment reflects the end or outcome of critical thinking and clinical reasoning (AACN, 2008). To avoid error and to meet the needs of patients and families, nurses must attentively use these three ways of thinking along with the nursing process (Walton, 2017). Rather than relying on reaction to a situation, intertwining the use of these skills is part of professional responsibility and quality of nursing care (Carvalho et al., 2017). The nurse uses a higher level of cognitive skills and communication/collaboration abilities to recognize and respond in a timely fashion to alterations, prediction of outcomes, and selection of the best logical action for an individual’s unique situation (Carvalho et al., 2017; Papp et al., 2014; Peeters & Boddu, 2016).

Table 4.1

Distinguishing Among Ways of Thinking Terms

Term	Definition Summary
Critical Thinking	Decision-making process
Clinical Reasoning	Extends the decision-making process to integrate and analyze information, and then make decisions about patient care
Clinical Judgment	End or outcome of critical thinking and clinical reasoning

Note. (American Association of Colleges of Nursing, 2008)

Intellectual Traits

Those who wish to become nurses arrive at school with a wide range of educational and life experiences. A challenge for nurse educators is to embrace the nursing students’ backgrounds and build on preexisting strengths while redirecting weaker areas that need improvement. The presence of intuition and logic for development of critical problem-solving abilities is indispensable in the student. Alfaro-LeFevre (2017), a leader in these concepts, compared thinking and critical thinking. “Critical thinking is controlled and purposeful, using well-reasoned strategies to get the results you need” (Alfaro-LeFevre, 2017, p. 5), whereas, conventional thinking can be mindless and routine, like the act of walking.

Ideally, intellectual traits, such as empathy, integrity, and reason, mature as critical-thinking dynamics expand. Nursing requires the ability to reason to analyze situations logically; however, as the professional develops, the ability to reason incorporates new insights, often from other disciplines. For example, as the baccalaureate nurse grows, logical analyses from sociopsychology, education, theology, and natural sciences influence the nurse’s perspective and resources. Integrity, or honesty, is an expectation of a nurse, and yet nursing students are caught cheating on examinations and assignments as well as plagiarizing papers. Recognizing the importance of respect and the need to protect integrity helps student nurses grow in their understanding of the ways of thinking and professionalism. Last, but not least, empathy is a voice of caring by the nurse. Nurses cultivate therapeutic relationships to relate to and understand the thoughts and feeling of patients and families. Empathy involves awareness and reduction of personal attitudes, bias, and stereotyping. Patients and families need to feel safe to express feelings, thoughts, and concerns without fear of a negative backlash in care. Emotional support fosters patient health. Maya Angelou noted, “As a nurse, we have the opportunity to heal the heart, mind, soul, and body of our patients, their families, and ourselves. They may not remember your name but they will never forget the way you made them feel” (American Association of Post-Acute Care Nursing, 2016, para. 9).

Measureable Behaviors

Nursing educators must coach students as advisors and role models, and monitor student behaviors. Likewise, preceptors and managers evaluate the novice nurse or new employee for evidence of critical-thinking abilities through discussions and results of care delivery. Empathy, use of the nursing process, reflective thinking, and use of evidence-based practice should be apparent. When nurses apply critical-thinking abilities, ethical reasoning, and honesty, integrity and ethical analysis are present in care delivery discussions and outcomes. Without compassion, the caregiver can become indifferent to the needs of the patient. This trait is challenging to foster if not already present. Another important character trait for nurses to possess is humility. Sometimes students and newly licensed nurses believe they already possess the intuition, logical thinking/problem-solving skills, and compassion needed for the profession, and do not wish to consult with others before caregiving. This becomes dangerous if the novice forges ahead in care decisions and delivery without consulting the coach. Listening and submitting to experienced nurses to determine the best care is important as novices learn to discern the complexity of the patient situation. Similarly, new nurses should exercise caution and avoid being a sponge, absorbing everything from the experienced nurses. Observing, questioning, and responding to questions with experienced nurses helps in the growth of critical-thinking and clinical-judgment skills; hovices may be eager for credibility regarding knowledge and skill abilities, along with independence, and may find patience taxed by the need for consultations. Because a portion of critical thinking, clinical reasoning, and judgment behaviors are cognitive or affective, measurement of the behaviors is a great challenge to nursing educators and health care administrators. Evidence of psychomotor behaviors is easier to obtain and analyze. Those in such evaluative positions seek the best practice for measuring these behaviors in professional publications and through networking. While working through the nursing program, students experience multiple assignments to enhance and evaluate skills in critical thinking. The novice experiences an evaluative period as well. More recently, internship programs serve to provide mentorship and monitoring as the novice grows.

Building Critical Thinking Skills

Building critical-thinking skills occur through the development of clinical reasoning and clinical judgment and vice versa. The process is highly interactive. The skills, guided by standards and scope of practice, codes of ethics, and laws, complement the nurse’s grounding in the nursing process and evidence-based practice. The process of building critical-thinking skills requires dedication to awareness, reflection, interpretation, and implementation. According to Alfaro-LeFevre (2017), the development of critical-thinking skill requires the nurse to gain insight and self-awareness, build trust, establish mutual communication in relationships, use evidence-based references, commit to the attitudes, knowledge and skills required for critical thinking, and seek formal and informal feedback of thinking and actions taken. Often, critical-thinking skill assignments use reflective narration to enhance self-awareness, communication abilities, and reflective evaluation of actions and outcomes. Nursing educators and preceptors often ask the nursing novices to break the nursing process into subcomponents in which the novice comes to the experienced nurses before taking the next process step. This aids the interpretation process before implementation of direct care. Sharing patient assessment findings with experienced nurses allows intentional time for reflection and interpretation of the implications of the information. This also increases effectiveness in oral and written communication skills. The time out in the process allows input from the seasoned nurses along with methods to draw out the novice’s critical reasoning with questions about the assessment, analysis, and plans for care. Nurses’ abilities to state rationale have been critical to the profession. Now, the rationale has expanded from textbook regurgitations of information to reasoning applicable to the individual patient’s condition. Socratic questioning of “why” may occur, as in, “Why do you think this is the best intervention?” or, “Help me understand why you think that this assessment data means that the patient is better than the previous assessment.” The nursing process continues onward to the interventions step after agreement occurs regarding the novice’s assessment, analysis, nursing diagnosis, outcomes identification, and planning. The educator or coach may accompany the novice through the implementation process for safety and quality care, depending on the previously assessed skill level of the novice. The mentoring communications resume to evaluate the outcomes of care given and to make decisions for follow-up. In a nursing program, students may have a journaling assignment to reflect further on the events of the day.

Clinical Reasoning

Benner’s 1984 landmark model development regarding growth process from layperson into a nursing role demonstrated that clinical reasoning does not occur overnight. The approach of novice to expert denotes the need to coach new nurses throughout the nursing education process and onward in licensed, clinical practice. In 2010, Benner, Stuphen, Leonard, and Day defined clinical reasoning as the “ability to reason about a clinical situation as it unfolds as well as patient and family concerns than the context” (p. 46). Baccalaureate preparation provides exposure and application of multiple ways of thinking and reasoning. Measures for learning clinical reasoning and clinical judgment skills are within present-day prelicensure nursing programs. Still, experienced, baccalaureate-prepared nurses coach newly licensed nurses as they transition student skills to licensed practice, helping them to grow in clinical reasoning and clinical judgment abilities, as ongoing enhancement of these skills is part of professional accountability. The dynamic and complexity of patient care and use of technology today demand that the professional caregiver quickly employs these skills to prevent health care errors and omissions, incomplete care, and failure to recognize or respond to failing clinical status.

Nursing Process

The nursing process is a decision-making process and provides the foundation for the profession’s problem-solving abilities. The nursing process implies the use of critical thinking, clinical reasoning, and clinical judgment. This critical thinking and reasoning model adopted by the American Nurses Association (ANA), prevails in all ANA standards and scopes of practices. The Nursing Scope and Standards of Performance and Standards of Clinical Practice (ANA, 2015) is the most recent scope and standard of practice publication, which applies to all nurses. The nursing process is found in Standards 1 through 6 of the publication. This edition identifies the components of the nursing process as assessment, diagnosis, outcomes identification, planning, implementation, and evaluation (see Figure 4.1).

Figure 4.1

The Nursing Process

The nursing process usually proceeds circularly from the assessment component through evaluation, although some perceive the process as proceeding top to bottom, starting again with the assessment moving down to evaluation. With either perception, the process is ongoing. Once the nurse reaches evaluation, the process resets or loops back to the assessment step. Meanwhile, a flow of information exchanges occurs between each component with all the other components. This information flow or feedback directs the nurse’s return to previous process steps. Information gleaned from one process step influences the others. The feedback loops require the nurse to recognize the complexity of patient conditions and independently employ critical thinking, clinical reasoning, and clinical judgment. Through experience and ongoing education, nurses increase critical-thinking abilities in the use of the nursing process. Baccalaureate education of nurses expands students’ understanding using theory from other disciplines, evidence-based practice, health promotion, safety and quality measures, genomics, informatics, and nursing along with community and global awareness. For example, the BSN-prepared nurse has more background incorporating theories regarding ethics, change, leadership, systems, and social justice, which influence critical perceptions of situations. The emphasis on evidence-based practice is notable. The ADN-prepared nurse incorporates knowledge of science into care for patients and families. The BSN-prepared nurse integrates science and other disciplines and critically appraises published research to use as a foundation of evidence-based solutions when caring for patients, families, and communities (National League for Nursing, 2010). This education enhances the nurse’s critical-thinking abilities within the use of the nursing process.

Ethical Reasoning

The awareness, reflection, and interpretation processes of critical thinking incorporate the nurse’s personal moral and professional values. As the nurse advances in professional development, questions will arise about whether something feels like the correct thing to do, whether an action is legal, whether fair and equitable treatment is being provided, and whether one is avoiding his or her personal bias. Determining whether any health disparities are present requires analyses of psychosocial, cultural, and spiritual facets for the nurse, patient, and family. As the nurse broadens in ethical understanding and social justice principles, clinical reasoning skills expand. Implementing ethical choices and experiencing results that promote human health and well-being reinforces the change in perspective.

Clinical Judgment

Alfaro-LeFevre (2017) defines clinical judgment as the result or outcome of critical thinking and clinical reasoning. Tanner (2006) reviewed nearly 200 studies of clinical judgment, arrived at five conclusions, and developed a model of clinical judgment (see Figure 4.2). Tanner fashioned the model to depict the noticing, interpreting, responding, and reflecting behaviors of clinical judgment in nursing. The nurse must be aware of the situation or notice what is happening. Then the nurse interprets the stimuli using analytic reasoning, ethical reasoning, narrative skills, and intuition. At that point, the nurse responds by choosing evidence-based and analyzed purposeful actions. The final step is the reflection on the action and lessons learned by the process and outcomes.

Figure 4.2

Tanner’s Five Conclusions

Note. Adapted from“Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing,” by C. Tanner, 2006, Journal of Nursing Education, 45(6), p. 204. Copyright 2006 by the Journal of Nursing Education.

Ethical Practice in Nursing

Philosophies of life result from values, assumptions, and beliefs gleaned from influences of childhood upbringing, life experiences, culture, spirituality, peers, and community. The individual’s philosophy drives decision making when faced with ethical or unethical behaviors. Nurses have the additional influence of their profession’s philosophies regarding ethical values and actions. Ethical issues occur in every health care environment; thus, they are part of every nurse’s practice. To uphold professional standards, nurses require knowledge, skills, and resources (Rushton & Broome, 2015). Ethical issues arise from various viewpoints about the differences between right and wrong. The viewpoints are common among society and religious beliefs as moral truths. For example, the Grand Canyon University (GCU) Ethical Positions Statement reflects this value. The position statement supports that knowing the difference between right and wrong reflects Christian beliefs, values, and practices and that those who follow Christ “should strive to live in a way that Christ lived both in private and in public” (Grand Canyon University [GCU], n.d., p. 12). Because situations involving ethics integrate within nursing practice, the nurse should understand ethical principles, theories of ethics/morality, applications to nursing practice, and components of ethical situational analysis. Baccalaureate education provides opportunities to expand knowledge, skills, and tools to face ethical issues and elevate professional standards.

Ethical Principles

Ethical principles are fundamental truths or foundational ethical values. Eight principles common within health care ethics are autonomy, beneficence, fidelity, justice, nonmaleficence, privacy,confidentiality, respect, and veracity. Ethical principles are not law, but the principles have become duties of the health care profession (see Table 4.2). The public expects nurses to demonstrate good moral character. Nurses exercise choice to follow the principles as a part of the profession’s inherent respect for humankind. Choosing to follow ethical principles displays the nurse’s commitment to the profession and those receiving health care. GCU supports such respect. “As a Christian institution, GCU affirms that every human being is precious to God and should be treated with the dignity and respect. …The university affirms the sanctity of human life and the intrinsic value of every human being” (GCU, n.d., p. 6). Drought (2002) noted that nurses function at the core of humankind with a practice tied to the vulnerability of the patient and morality.

Table 4.2

Ethical Principles

Ethical Principle	Concepts/Duties
Autonomy	Supporting a person’s right to self-determination; respecting a person’s rights, values, and choices
Beneficence	Doing good; actions benefiting others versus risk of harm; best care
Fidelity	Loyalty; keeping promises
Justice	Sense of fairness and equity of distribution; what is deserved; no favoritism
Nonmaleficence	Doing no harm; not to intentionally inflict harm; consideration for the degree of risk
Privacy and Confidentiality	Right to control one’s personal information; self-determination for the amount of private information to reveal; respect for and nonrevelation of a person’s private and sensitive information
Respect	Treating every person as a worthy individual; honoring autonomy and protection for those with diminished autonomy
Veracity	Truthfulness; honesty; truthful disclosure of information; integrity

Nursing Ethics in Practice

Part of growth as a nurse is the application of an inner conscious or moral compass into professional practice (Eklund, 2016; Lachman, 2009; Lachman, 2012). According to Lachman (2016), a code of ethical conduct delivers “the legal and professional outline for answerable and accountable practices across the profession” (p. 429). The most prominent code of ethics for nurses in the United States is the recently revised ANA Code of Ethics with Interpretive Statements (2015). Ethical duties of registered nurses are declared through nine provisions (see Table 4.3). Interpretive statements provide a broader basis for understanding how to apply the provisions (Rushton & Broome, 2015; Lachman, 2015; Winland-Brown, Lachman & Swanson, 2015). These ethical principles are prominent in the interpretive statements.

Table 4.3

Provisions of the ANA Code of Ethics for Nurses

Provision 1	The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
Provision 2	The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.
Provision 3	The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.
Provision 4	The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
Provision 5	The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
Provision 6	The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
Provision 7	The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
Provision 8	The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
Provision 9	The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Note. Adapted from “Code of Ethics for Nurses with Interpretive Statements,” by the ANA, 2015, p. v. Copyright 2015 by the ANA.

Ethical codes for nurses are not limited to the ANA’s Code of Ethics for Nurses with Interpretive Statements (2015). Specialty organizations may have their code of ethics; moreover, nursing is a global profession. For example, the International Council of Nurses (ICN) focuses on quality nursing care and health policies worldwide.The ICN Code of Ethics for Nurses (2012) stated that four elements frame the standards of conduct: “nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers” (p. 4).

Nurses Role in Ethics

Pressures and anxiety occur when ethical issues arise. Nurses often feel stress when arriving at or participating in decisions attempting to resolve ethical dilemmas. In these instances, nurses greatly influence the health care environment by acting as an advocate for ethical decision making. “Nurses encounter these challenges in many settings and are uniquely positioned to speak up to influence decisions that will lead to the right actions and to establishing an ethical practice environment” (Cipriano, 2015, p. 3). Nurses face pressures because of both societal and rapid health care system transformations (Johns Hopkins Berman Institute of Bioethics, 2014).

Nurses feel these pressures and the intense array of ethical issues that they raise. At the same time, research shows that patients and health care organizations fare better when nurses can be reflective, and are supported in their work environments in the practice of high-quality, ethical care (para 2).

Pressures arise from issues regarding informed consent, questionable research practices, end-of-life care, and many other types of additional ethical scenarios. Drought (2002) noted, “The human intimacy and vulnerability that we are privileged to witness creates a duty to protect the privacy of the patient and the confidential nature of what we see and learn” (p. 239). Nursing was founded on the aspects of services to others. Service and respect for others remain a constant nursing value while giving care across the life cycle (Rushton & Broome, 2015). Nurses are empowered to be the patient’s voice or advocate, protecting ethical principles of autonomy, nonmaleficence, confidentiality, and other ethical principles.

Different Levels of Nursing Ethics

Opportunities for nursing to employ ethical behaviors occur at every level of health care: patient, organization, professional, state, national, and international levels. The nurse is empowered at the patient level as difficult patient situations occur, such as informed consent, treatment choices, end-of-life decisions, cultural differences, and family versus patient preferences. At the organizational level, the environment reflects the ethical beliefs of the organization. In larger organizations, more opportunities exist for nurses to collaborate with other nurses and disciplines when facing ethical issues. The resources are generally more abundant at larger organizations, whereas smaller facilities may have fewer pairs of eyes to note an issue. The number and types of issues may be more diverse in larger organizations, such as metropolitan teaching or research facilities; however, no matter what the size of the organization, everyone must be aware of possible ethical issues and be willing to act to prevent harm. No one wishes to be in situations in which such harm occurs. The classic case of murderous Dr. Michael Swango conveys ethics at the organizational level; people in multiple states who worked at hospitals with Dr. Swango reported feeling that something was not right (Stewart, 1999). If the ethical conduct is not congruent with the ethical code of conduct governing nurses and health care, a far-reaching ethical dilemma arises for both the nurse and the patient for best care decisions. Additionally, the nurse supports the patient during conflicts with greater ease if he or she knows that the organization supports patient advocacy. At a professional level, empowerment occurs through advocacy efforts of national and international organizations. On a political level, nurses are of such a large number that the profession amasses a large voice that politicians listen to on local, state, national, and global levels.

The ANA Code of Ethics (2015) defines metaethics as the “nature of ethics and moral reasoning: right vs. wrong; good vs. evil; normative ethics; ethics of right and wrong in human action—what we ought to do; good evil-what we ought to seek to be” (p. 15). Studies on theories of metaethics abound, but the most common theories influencing health care are deontology, utilitarianism, and virtue ethics (see Table 4.4). The theories provide guidance toward various perceptions of problems versus a one perception fits all approach. These theories are foundational to codes of ethics and logical reasoning.

Table 4.4

Theories of Morality

Theories of Morality	Main Concepts
Deontology	Duty-based; focuses on obligation to others. In the 18th century, Immanuel Kant emphasized respect for the dignity and worth of every individual. Under deontology, actions are not a means to the end, but rather based on right action for the social duty of treating others with respect, dignity, and worth.
Utilitarianism	Outcome based; in other words, it centers on the end outcome of human actions. In the 19th century, John Stuart Mill concentrated on actions that would result in the best outcome for the largest number of people; thus, simplified as actions for the greater good. The end justifies the means.
Virtue Ethics	Character-based; agent based; in other words, whether a good, honest, or generous person would perform the act in question. Virtue ethics is not action-based as in the two previous theories.

Ethical Analysis

An ethical dilemma is a situation in which a choice is required among options, none of which will resolve the situation in the most favorable ethical manner. Applied ethics are the various approaches to ethical dilemmas. Applied ethics “wrestles with questions of right, wrong, good, and evil in a specific realm of human actions, such as nursing, business, or law” (ANA, 2015, p. 15). This involves the use of logical reasoning, ethical analysis, and in the case of nursing, critical thinking and clinical judgment. Ethical dilemmas may result from issues such as whether to continue life-sustaining actions or end-of-life treatment. Conflicts can occur involving family dynamics, religious and cultural beliefs, and other factors. Sometimes situations result in a convening of an institution’s ethics committee, composed of multidiscipline representation. Issues are forwarded to the committee’s attention through institutional policy and/or chain of command. Nurses are encouraged to participate on ethics committees if an opportunity arises. The nurse is responsible for learning the process for that setting, including the existence of an ethics committee, committee composition, times of meetings, and access to the committee should the need to convene occur. Moreover, the nurse is responsible for knowing the members of the chain of command because when issues and dilemmas occur, they are the timeliest and most closely connected resources to the nurse for assistance; however, not every ethical analysis is handled within a committee structure. Ethical dilemma analysis usually uses the following components: medical indication for treatment, risk-benefit analyses, alternatives, patient preferences, quality of life predictions, and pertinent external factors. The analysis process applies components from the theories of morality. The nurse’s role is an advocate for the patient.

Check for Understanding

1. How are ethical dilemmas analyzed where you are employed?
2. Whom do you contact when an ethical dilemma occurs in the workplace?

Common Ethical Dilemmas

Nurses encounter a variety of ethical dilemmas. Every dilemma must be resolved on a case-by-case basis. There are no magical standard answers to these situations.

Informed Consent: Will the outcome be affected or rights violated if the sparse information is provided to a patient? How is the nurse certain of informed consent when the person has dementia or an intellectual disability? What happens when an option is best, but not affordable? What happens when a viable option is not presented because the practitioner does not believe it is best for the patient? When does the nurse intercede?

End of Life: How is quality of life determined? How is pain relief determined? How are patient preferences determined without prior conversations with a surrogate decision-maker or advanced directives? When families conflict over end-of-life decisions, how is this resolved? If a fetus is involved, how is conflict resolved over the possible life of one over another? What is the nurse’s role?

Impaired Caregivers: Evidence of a coworker’s use of mood-altering substances in the workplace demands immediate intervention. Nevertheless, what does the nurse do with suspicions without evidence? What if the nurse does nothing and a patient is harmed? What if the nurse is wrong; what happens to the working relationship?

Staffing: How do patient acuity and skill mix affect the ability to protect patient rights, treatment complexities, and educational needs? How does the nurse avoid becoming jaded or worn? How is quality care versus economic cost measured and weighed?

Professional Obligation and Responsible Care

Lifelong Learning

Nurses have a responsibility to remain current in nursing and health care practices. Laal (2011) defined lifelong learning as a means of learning that “should take place at all stages of life cycle (from the cradle to the grave) and, in more recent versions that it should be life-wide; that is embedded in all life contexts from the school to the workplace, the home and the community” (p. 471). Lifelong learning for nurses encompasses many formats. Formal education in the form of higher collegiate degree is one method. Continuing education, workshops, conferences, and summits also contribute to expanding nursing knowledge and skills. Most states require evidence of ongoing education for continued licensure, reinforcing the expectation of ongoing development. These boards, charged with protecting the public, require continuing education credits as evidence of protection. A nurse practicing in a state without these requirements has expectations from peers and the profession for current, safe, quality practice through lifelong learning. Reading professional journals on a routine basis supplies current, relevant information to the nurse. For example, networking with other nurses through professional organizations informs nurses regarding emerging issues. Keeping abreast of current political information and news regarding health care is still another method of lifelong learning. Lifelong learning is vital because it keeps the patient, nurse, and families safer through growth in knowledge and skills for assessment and awareness of changes in evidence-based practice. Education helps nurses advance quality care and health promotion. Learning empowers the nurse and enhances credibility with the public, peers, and other disciplines.

Empowerment

“Because nurses are allowed to touch people physically and emotionally in ways others cannot, that level of trust imposes on nurses certain obligations not always shared by the general public” (Lanier, 2016, p. 18). The codes of ethics detail a nurse’s obligations. “Licensure is a covenant, between privileges upon nurses as well as duties” (Drought, 2002, p. 238). The trust of the public and privileges of being a registered nurse demand the provision of safe, quality, ethical care. This mandate necessitates keeping abreast of changes in technology, politics, scientific discoveries, health care treatment trends, and ethical issues. Also, choosing to practice in settings that support and value one’s beliefs provides additional inspiration, confidence, and empowerment. The nurse who remains current to the dynamics of the profession and health care is empowered to trigger or participate in change.

Refreshing the Basics: Laws

Legal system concepts are foundational to nursing practice. For some, this content may be familiar, offering a refresher of current understanding, while for others, this may be new. Because nursing practice is both permissible by law and affected by the various areas of law, the following aspects should be reviewed to confirm knowledge and understanding.

The United States legal system contains laws arising from three main sources: 1) judicial or common law, 2) legislative law, and 3) constitutional law. An overview of privacy in health care can aid in better understanding these sources. Constitutional laws reflect rights stemming from the federal and state constitutions. Long before the Health Insurance Portability and Affordability Act of 1996 (HIPAA), a federal constitutional right to privacy was recognized in the legal system. Unfortunately, laws do not address specific scenarios and are open to interpretation, which in turn leaves these interpretations of the law open to debate and sometimes leads to court cases. Legislation and standards of practice uphold nurses’ obligation to maintain a patient’s right to privacy and confidentiality.

Passage of legislation, also known as statutes, provides guidelines that are more specific. In this case, the United States Congress passed HIPAA to define and refine to whom disclosure of personal medical information was permissible and under which circumstances. HIPAA was not restricted to the health care professional, but directs anyone who deals with health care information. Sharing information to those without a specific purpose became a violation of federal law.

Judicial law, also known as case law or common law, is the ruling of a judge or judges. No matter how specific a legislative law may seem, applying the law can result in scenarios that do not have a clear determination. A judge or judges weigh the constitutional, legislative, and other case law against the facts of the scenario presented to the court. A jury may or may not be involved in reaching the verdict or decision for the case. The court’s ruling determines how that law applies to the scenario and becomes case law or precedent for future interpretation of such a situation; therefore, a practice violation could become a court case with a court determining if a violation occurred and corresponding penalties. Civil cases result in monetary damages as penalties. Criminal cases result in monetary damages and/or imprisonment.

Various categories of law exist that encompass aspects of judicial, legislative, and constitutional law, such as contract law, labor law, criminal law, civil law, and family law. Nursing practice focuses on two of the categories: criminal law and civil law. Criminal law involves laws, usually from legislative statutes, designed to punish those who endanger, threaten, or harm the health and safety of others or their property. The criminal laws are created to protect individuals, communities, and society. The penalty may be death, imprisonment, a fine, or a combination of the latter two. Criminal laws and nursing practice intersect in the areas of violence or abuse, illegal drug use, and intentional harm.

Civil law, also known as tort law, is an action against an individual or group causing damage that requires compensation or restitution to restore the person(s) to his/her/their state before the damage. The three classifications of civil laws are negligence, intentional torts, and strict liability, usually product liability. All three classifications influence nursing practice. For example, a defective infusion pump requires nursing actions to notify others through various reporting routes, including providing information for the institution’s report to the FDA. Preservation of facts and equipment surrounding the pump difficulties and accurate, factual documentation is imperative for determination of product liability in a situation of a potential manufacturer defect. The nurse is responsible for learning the organization’s procedure for collecting this information. Some institutions have an identified person, such as a paralegal in risk management, who maintains the forms, records, and evidence for the reporting process to the FDA and manufacturer. In other institutions, the process may be through the purchasing department or quality improvement department. The important issue is the removal of a potentially harmful piece of equipment from patient care and reporting it according to the organizational policy and procedure. Some organizations have references to FDA resources as part of the written process.

The topic of intentional torts is topical in all prelicensure programs. For example, nursing programs discuss how to avoid false imprisonment of a patient; however, the real-world application can be challenging in the heat of the moment. If a patient wishes to leave without a discharge order, the nurse may be inclined to say, “You can’t leave,” or “If you go, your insurance company won’t pay your bill,” or “You must sign this paper or I cannot let you go;” however, none of those statements are necessarily true. The nurse is liable for falsely imprisoning the patient who felt a threat to his or her autonomy to leave. Conversely, there are times when a patient can be held without violating the patient’s autonomy, such as when the patient is a danger to self or others. Autonomy and informed consent laws were fashioned from common (judicial) law cases in which the patients lacked information of possible outcomes before a procedure. Undergoing anesthesia, but awakening to an unexpected hysterectomy is a violation of one’s autonomy or ownership of one’s body. Generally, the person conducting an invasive procedure is required to inform the patient of the risks, benefits, and alternatives to treatment. Usually, evidence of informed consent is given when the patient or surrogate signs a consent form, indicating that the patient is freely giving his or her body or autonomy for the procedure. A nurse may witness the patient’s signature on the consent, yet does not hold the responsibility to inform a patient of the risks, benefits, and alternative treatments for a procedure performed by another. The practitioner performing the procedure holds the liability to follow professional and statutory standards for informed consent.

Negligence, however, strikes fear in the hearts of many from the beginning. When someone’s carelessness causes harm, the act is negligence. Malpractice is the term used when negligence occurs by a professional. Nursing is a caring profession, so the idea that one would harm a patient is abhorrent. Harming a patient because the nurse did something wrong often relates to negligence. Negligence involves several factors or elements: duty, breach of duty, injury or harm, and damages (see Figure 4.3). Nurses have a duty of care to the patient. When the nurse makes a mistake or omission in care (i.e., breach of duty), the patient experiences harm. The patient can choose to sue the nurse and others for the harm. A court may award monetary damages to restore the patient. Of course, this of is a very simplified explanation. One experiences shock and grief from harming the patient and from the court experience itself. The financial burden can be even more devastating if the nurse does not carry malpractice insurance.

Figure 4.3

Elements of Negligence

Laws also protect the nursing practice. Many acts performed as part of the nursing practice have penalties for those who pose as nurses without educational preparation, competency, and licensure. Other statutes and cases protect nurses’ right to identify credentials such as “RN” to patients, on name badges for example. This protects the profession and the public from those who portray themselves as nurses but are not. Also, protection exists for aid given in emergencies outside of the work setting, commonly referred to as Good Samaritan Laws. Good Samaritan Law is based on the biblical parable of a Samaritan who provided roadside aid to an assault victim who had been ignored by two previous travelers (Luke 10:23-37). The rescuer showed kindness and mercy, even though the Jewish victim likely would have shown contempt for any Samaritan. If a health care professional finds someone unresponsive on the street, is the duty of care to begin resuscitation measures an ethical one or a legal one? Is the professional’s choice swayed by the age or probable cause of the event, such as witnessing the cardiac arrest of a frail, older person or a known opioid overdose respiratory arrest in an emaciated young adult? In the parable, the biases of the previous travelers hindered them from providing aid to the assault victim. In most states, there is not a legal duty for the passerby. The term Good Samaritan Law invokes a sense of security that one may respond to emergencies without fear of legal reprisal. The law fosters quick response to emergencies for the good of the public; however, that protection extends only if one performs within the scope and standards of practice and without negligence or misconduct. The limits of Good Samaritan Law protections can serve as an incentive for understanding the scope of practice and standards of practice.

The previous content is a foundation for the subsequent sections of this chapter. Safety and quality have ethical, legal, and moral implications that require the use of critical thinking and clinical judgment. Health promotion is a logical outcome of the same. Nursing leadership opportunities arise in the ever-changing health care scene. Understanding and awareness of the role is foundational and yields an increasingly knowledgeable nurse who is prepared for the challenges.

Scope of Practice and Standards of Practice

Scope of practice and standards of practice tend to be used interchangeably. The terms imply a means of regulation and accountability for the practice of nursing (see Table 4.5).

Table 4.5

Differentiation between Scope of Practice and Standards of Practice

Scope of Practice	Standards of Practice
Extent of practice; practice boundaries	Minimum standard for proficiency and competence; also known as standards of care
Professional practice activities defined under state law (i.e., Nurse Practice Acts and rules and regulations). Some states have specific sections or resources noted for that state’s scope of practice	Professional practice activities defined under state law (i.e., Nurse Practice Acts and rules)
Specialty organizations publish relevant documents to define the scope further for that area	Define quality of care; provide specific criteria for the determination of quality of care
“The ‘who,’ ‘what,’ ‘where,’ ‘when,’ ‘why,’ and ‘how’ of nursing practice” (ANA, 2010a, p. 13)	Provision of practice activities in a consistent manner, meaning that another nurse with similar education and experience would provide care in a similar fashion

Scopes and standards in conjunction with codes of ethics are foundational to registered and advance practice nurses. From the first nursing course of a prelicensure program and forward, nursing students learn to practice within the boundaries of the nursing role and complete actions within the standards of nursing practice. A challenge in the initial nursing course is refuting the myths about what a nurse can and cannot do. Some students come to the program with a previous role in a health care setting, such as a pharmacy technician or patient care assistant. Accompanying the experience were positive and negative role models, and thus various perceptions of the nurse’s role. Others come with the perspectives formed by exposure to the various printed or electronic media versions or other fictitious characterizations of the role. The nursing student must push aside the preconceived perceptions of the role and embrace the true scope or boundaries. Students entering an advanced program such as the RN-BSN program at GCU have had some time gaining experience at the bedside. With experience comes the understanding of how these standards are applied and why the scope of practice is so imperative to patient care. Baccalaureate prepared nurses gain a greater understanding of the standards and scope, enabling them to coach and assist novice nurses in understanding their importance (see Figure 4.4).

Figure 4.4

Determinants of Nursing Practice

The scope of practice provides the freedom to apply educated critical thinking and skills into the provision of care within defined parameters. The parameters protect the public and the profession. Steps toward understanding and demonstrating the profession’s freedoms and the constraints begin with a nursing program education, progress to licensure, and continue with ongoing, lifelong learning. Obtaining licensure is not an easy undertaking. By the time of licensure examination, the candidate has the basic understanding of what actions are permissible within the role. Nevertheless, the person may or may not have read the Nurse Practice Act of the state in which he or she is practicing, relying only on educational exposure to the role.

Scenario

Before arriving, an anesthesiologist expects that the catheterization lab nurses will have obtained and administered a preprocedural medication even though he had not provided them with an order. While it may seem obvious that the response to this is, “I cannot do that without an order,” nurses habitually override the medication vending system and administer the medication because everyone gets the medication and the anesthesiologist eventually writes an order. This is wrong! The nurses are acting beyond the scope of practice for nonadvanced practice nurses. The act of obtaining and administrating the medication without an order is prescribing and not within the practice boundaries.

Nurse Practice Acts

Each Nurse Practice Act is the state-specific statutes addressing the scope and standard of practice; thus, Nurse Practice Act content varies from state to state. The statutes commonly require standards for nursing educational programs, types of and requirements for nursing licenses, and grounds for disciplinary actions. Some states, such as Ohio, subtitle specific sections delineating the scope from standards of practice. Each state’s Nurse Practice Act creates and empowers a board of nursing, which further refines the statutes through the development of administrative rules, known as rules or rules and regulations (see Table 4.6). The rules, once adopted, have the strength and effect of state law.

Table 4.6

Differentiation Between Nurse Practice Act and Rules

Nurse Practice Act	Rules
Laws/Statutes determined by the state legislature through the lawmaking process	Rules and regulations developed by the board of nursing and adopted through the board or state process; have the power and effect of law
Specify the requirements for safe nursing practice within the state	Stipulate the plan for safe nursing practice within the state
Identify the role of nurses, along with the scope and standards of care required for practice of nursing within the state	Refine the scope and standards of care required for practice of nursing within the state
Prescribe the need for continuing education and licensure renewal	Set standards for continuing education programs and license renewal
Creates the state board of nursing, the board membership, funding, and powers, including police and disciplinary powers	Guide board enforcement of the Nurse Practice Act/rules and implementation of disciplinary due process with remediation or penalties
Requires safe delegation of nursing care	Specify responsibilities within the practice, such as how effective, safe delegation occurs

Each board of nursing has police powerto protect the public from harmful nursing practice. The board’s primary objective is to serve the public, not nurses. Each nurse must guard against practices that would put patients at risk and report to the board any violations others have committed. At-risk behaviors for nurses include legal or illegal drug impairment while in the work setting, drug diversion and theft, theft from a patient, physical or sexual abuse of a patient, emotional abuse or boundary crossing of a patient, falsifying documents, and other criminal conduct. Generally, each health care institution has an internal chain of command for this reporting process. The nurse witnessing the situation should report within the institutional guidelines. Furthermore, the nurse is legally obligated to report unsafe nursing behaviors to the state’s board of nursing. Each board has a process for investigating allegations of unsafe practices. If the allegations are a violation, the involved nurse receives a hearing in which the nurse may present a defense. Nurse Practice Acts and corresponding rules and regulations specify how the due process proceeds. Disciplinary actions can be fines, temporary suspension of licensure, permanent suspension of licensure, and/or practice restrictions, such as being banned from administrating narcotics. Disciplinary actions are public record for public awareness and protection.

The state board of nursing is the owner of a nurse’s license, not the nurse. A nurse facing allegations of misconduct in a board of nursing investigation must respond promptly and cooperate with the board. Sometimes, such as cases involving impairment in which patient medication was not diverted, the involved nurse has the option of a voluntary temporary surrender of licensure while seeking help through a rehabilitation program. Usually, the nurse must seek out this option and promptly comply with time indicators for the process. Successful completion of the rehabilitation program includes counseling, abstinence, and monitoring. While frightening to surrender a hard-earned license voluntarily, success earns a return of licensure without a permanent notation on the nurse’s public record. Electronic records have made licensure records more easily available. Rapid licensure confirmation reports are available on state websites and through Nursys national data bank via the National Council of State Boards of Nursing (NCSBN) website. In the interest of protecting the public, information about licensure status, state board disciplinary actions, and practice privileges or restrictions are available to the public.

Malpractice

Nursing malpractice claims are on the rise according to a leading insurance carrier (Brown, 2016). Nurses should be concerned about malpractice litigation (Brown, 2016; Cooper, 2016; Sweeney, LeMahieu, & Fryer, 2017; Watson, 2014). The Medicare and Medicaid Patient and Program Protection Act of 1987 lead to the creation of the National Practitioner Data Bank (NPDB) under the U.S. Department of Health and Human Services. Since September 1990, the NPDB has stored reports regarding medical malpractice payments and adverse actions by health care practitioners, providers, and suppliers, including adverse licensure issues. Adverse action taken by a state board of nursing is reportable to the NPBD, and the report is electronically accessible to hospitals, plaintiff attorneys, other state boards of nursing, and other eligible parties, but not the public (National Council of State Boards of Nursing, n.d.). Sweeney, LeMahieu, and Fryer (2017) suggested malpractice data be analyzed and used to address areas of clinical weakness and improve quality of care and patient safety. Nurses must stay vigilant and safeguard themselves and others from acting negligently.

Not all nurses carry professional liability (malpractice) insurance, but should. Some mistakenly believe that an employer’s liability coverage is sufficient. Others believe the myth that if they hold a personal policy, they are more apt to be named in a lawsuit, believing the patient’s attorney seeks this individual source for payment of damages. Holding a personal policy has certain benefits. Employer coverage only extends to events occurring during the time of employment and on work time. Nurses are nurses 24/7. As health information and caregiving resources to the public, nurses do not limit actions to a setting. A nurse is liable at any time for perceived harm occurring in the workplace and nonworkplace settings. Lawsuits happen whether or not an error occurred. Also, a nurse does not always have the same perspective as the employer when an adverse event or lawsuit occurs. Sometimes, nurses act outside of the employer’s scope and standard of practice for the nurse’s position. This makes for a potentially adversarial relationship with the employer, and the nurse would benefit from the protection of his or her interests by the separate legal representation provided by the personal liability policy. The cost of a professional liability policy is minimal compared to the high cost of legal counsel and defense. Other benefits may be included that are not usually in employer policies, such as licensure protection benefits (Pohlman, 2015).

Check for Understanding

A surgeon orders, “Remove the g-tube.” The seasoned nurse, who has never removed one, enters the patient’s room, instructs the patient of the intent to remove the tube per the surgeon’s order, removes a skin suture, deflates the tube’s balloon, proficiently removes the tube, and documents the procedure with no harm to the patient. The Nurse Practice Act and regulations of the state say nothing about gastrostomy tube removal. The nurse knows nothing about practice and g-tube removal from specialty organization’s publications. The institution did not include the removal of gastrostomy tubes as a permissible procedure within the nurse’s scope of practice and practice standards or in the policy and procedure resource for the nurse’s guidance.

1. Did the nurse practice beyond the scope of practice?
2. If the nurse did not practice within the institution’s guidelines, will the nurse be directly liable for any harm? Will the institution not be held liable?
3. What should the nurse have done to avoid a practice issue?

Influences of Standards of Practice

Nursing programs endorse the concept of lifelong learning. Upon licensure, one cannot cease to think critically about the legal and organizational dynamics of the art and science of the nursing practice. Both the scope and standards of practice aim for prudent or sensible nurse behaviors. In other words, the aim is that one nurse’s thinking, behaviors, and direct actions would be like those of a different nurse with similar education in a similar situation. The nurse’s situation and experience are factors for consideration regarding what decisions and actions the nurse should determine after applying critical thinking; however, the core objectives are safety and the delivery of quality of care for the patient. Practices change over time, and technology is a rapidly changing influence that is shifting parameters. The public, including the legal systems, rely on the scope of practice and standards of care published by nursing specialty organizations. Health care organizations review and revise approved procedures for care within the boundaries of the system. Diligent attention to announced publications and revisions in the law, specialty practice, and organizational systems provides a dynamic platform for informed nursing delivery of care.

Institute of Medicine (IOM)

TheInstitute of Medicine (IOM), a nonprofit organization affiliated with the National Academies of Science, has become a major force for making the public aware of health care errors. In 1999, national media shared the IOM’s examination of problems within the United States’ health care systems. The report, To Err is Human, resulted in stories in national news media describing the tens of thousands of hospital deaths that occur annually from preventable medical errors. The report suggested a national focus on health care safety (IOM, 1999). Public outcry at the epidemic of preventable errors and demands for change spawned congressional hearings; accrediting organizations, insurers, professional groups, and others scrambled to define fatal and nonfatal events, develop reporting systems, and create strategies for nationwide change, such as raising performance standards. In 2001, the IOM’s report, Crossing the Quality Chasm: A New Health System for the 21st Century, modified the focus on errors and safety to a focus on quality as a means of safety and error prevention. Emphasis became safe, effective, timely, efficient, equitable, and patient-centered provision of care. Strategies incorporate customization of care based on an individual’s needs, continuous healing care, patient control over health care decisions, evidence-based practice, free flow of clinical information, and transparency (IOM, 2001; Wolfe, 2001). Soon health care jargon reflected these strategies. This focus persists through subsequent IOM publications, namely 2003’s The Future of the Public’s Health in the 21st Century and 2011’s The Future of Nursing: Leading Change, Advancing Health. The IOM reports reflect evidence that education level of nurses affects health care delivery and outcomes in terms of morbidity, medication error reduction, and length of stay (IOM, 2003; IOM. 2011). Professional organizations and accreditation bodies have urged skill mixes that reflect an increase of educational preparation of bedside nurses and the profession in general. The goal is that 80% of bedside staff will have earned a baccalaureate degree or an 80/20 skill mix of staff. Some health care organizations will not hire a nurse holding only an associate’s degree unless the nurse commits in writing to earn a baccalaureate degree, usually within 3 to 5 years. The health care organizations extend this expectation to nursing management with an expectation of obtaining a master’s degree or more advanced degree within 3 years of being hired.

Health promotion is a logical accumulation of safety and quality care efforts. Nurses understand that health improvements require advocacy for the public, opportunities for education of self and others, and removal of barriers to change. Several events are empowering nurses as leaders of health promotion, leadership, and advocacy, including the 2010 Affordable Care Act (ACA), the release of the IOM report, The Future of Nursing: Leading Change, Advancing Health, and the formation of The Future of Nursing: Campaign for Action. The latter two are presented here as part of the influence on nonprofit organizations on nursing and health.

The Future of Nursing: Leading Change, Advancing Health

With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. (IOM, 2011, p. 1)

The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) noted nurses’ commitment to improving care. The report declared that the nursing profession needs a transformation in the areas of practice, education, and leadership to improve health and care in the future. The IOM committee distinguished four key messages to guide the transformation:

1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States
4. Effective workforce planning and policy making require better data collection and improved information infrastructure (IOM, 2011, p. 4).

The report included eight recommendations for accomplishing the four key messages (see Table 4.7).

Table 4.7

The Future of Nursing Recommendations

Ethical Principle	Concepts/Duties
Recommendation 1: Remove scope-of-practice barriers.	Advanced practice registered nurses should be able to practice to the full extent of their education and training.
Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.	Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices.
Recommendation 3: Implement nurse residency programs.	State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.
Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.	Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan.
Recommendation 5: Double the number of nurses with a doctorate by 2020.	Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.
Recommendation 6: Ensure that nurses engage in lifelong learning.	Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.
Recommendation 7: Prepare and enable nurses to lead change to advance health.	Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses.
Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data.	The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

Note. Adapted from The Future of Nursing, Leading Change Advancing Health, by the Institute of Medicine, 2011. Copyright 2011 by the National Academy of Sciences.

The IOM, more recently known as the National Academy of Science, Engineering, and Medicine, is a highly respected institute. By making recommendations to remove many practice barriers in nursing, the IOM provided powerful credibility to the need for changes in nursing roles. Many in the nursing profession had already been trying to remove the barriers, but now the IOM’s spotlight made others take notice, increasing the power to advocate for revisions. Recognition that nurses with a baccalaureate education and higher result in fewer patient errors and deaths spurred a new demand for nurses with advanced education. The focus is changing from skills to outcomes, health promotion, and preventative care at the community, state, and national levels. Doors have opened for new roles in nursing, especially for advanced practice nurses. Recognition of how nurses tie the components of health care together is increasing. More institutions are implementing the role of nurse navigator or transitional care coordinator to help guide the patient and families as they traverse the various aspects of clinical care. These nurses weave the dimensions of health care into a clear picture of the path toward the best patient outcomes that include more education, less stress, and less burden of cost.

The Future of Nursing: Campaign for Action

TheFuture of Nursing: Campaign for Action (also known as the Campaign for Action) is a response to the 2010 IOM report and is dedicated to implementing the report’s recommendations. Never has a project formed to address the public’s increasing demand for care “by utilizing all skills, talents, knowledge and experiences of nurses” (Future of Nursing: Campaign for Action, 2011, p. 1). It is helpful for nurses to understand which public organizations support the movement and professional group activities

The American Association of Retired Persons (AARP) is the largest nonprofit organization representing persons ages 50 and older. The Robert Woods Johnson Foundation (RWJF), the largest health-focused philanthropy group in the United States, partnered on the 2010 IOM report that studied nursing’s role in transforming health care (Campaign for Action, n.d.a). The American Association of Retired Persons (AARP) and the RWJF joined forces to promote the Center to Champion Nursing in America (CCNA). After the IOM 2010 report was published, the CCNA developed The Future of Nursing: Campaign for Action with the goal of improving the nation’s health through nursing. “The Campaign’s work is focused on the following issue areas: improving access to care, interprofessional collaboration, nursing leadership, nursing education, nursing workforce data, diversity in nursing, and building healthier communities” (Robert Woods Johnson Foundation [RWJF], n.d. para 2). The Campaign for Action notes, “America’s 3.6 million registered nurses are key to promoting health and creating communities in which everyone has access to high-quality care” (Campaign for Action, n.d.c, para. 2).

RWJF provides grants for organizations improving the health of the nation and funds many of the campaign’s project activities. Each state and Washington, D.C. has action coalitions composed of advocates from nursing, businesses, health care organizations, and interested consumers to accomplish the work of the campaign at the local, regional, and state levels. The coalition has liaison representatives to the national campaign and activities posted on the national website (Campaign for Action, n.d.b). State action coalitions are seeking nurses from every level of nursing to serve as advocates for the profession, health care, and positive health outcomes. Nurses and diverse stakeholders for any state coalition meet to address specific nursing profession issues and work to create innovative solutions with nurses leading the way. The opportunity to lead the way is empowering for the profession. Moreover, having a voice in an open forum helps nurses take action to generate positive opportunities for growth in the profession, rather than passively waiting for change. For example, Ohio has subgroups generating plans and achievements such as increasing the number of BSN-prepared nurses in the workforce, leadership and advanced education, residency programs (transition to practice), scope of practice/nurses practicing to fullest extent of their license, data (research), and diversity (Ohio Action Commission, 2017).

The Joint Commission (TJC) and National Patient Safety Goals

TJC Vision

One way of assessing quality measures of an organization is through accreditation. To reduce bias, this assessment process occurs from independent, nonprofit resources. Probably the most noted among such resources is The Joint Commission (TJC), an organization for accreditation of health care organizations and programs. Founded in 1951 as The Joint Commission on Accreditation of Healthcare Organizations (JACHO), TJC’s mission is to “improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (The Joint Commission [TJC], 2018a). TJC’s vision is that “All people always experience the safest, highest quality, best-value health care across all settings” (TJC, 2018a). Onsite assessments or site visits of health care organizations occur a minimum of every 39 months to determine whether health care organizations or programs are meeting TJC performance standards (TJC, 2018b). The site visits, known as surveys, are unannounced. Laboratory surveys are every two years (TJC, 2018b). Loss of accreditation or poor accreditation reports are warnings for the public. In addition, poor results can be financially devastating to the organization with fines and loss of insurance payers for services, Medicare payment in particular. TJC accreditation is voluntary and benefits health care organizations and programs as a sign of quality to both the public and the professions.

National Patient Safety Goals (NPSGs)

During this century, TJC established a program to address specific concerns regarding patient safety and publish annual National Patient Safety Goals (NPSGs). The goals are kept current through consultation with an appointed panel of experts known as the Patient Safety Advisory Group. TJC, with advisement from the Patient Safety Advisory Group, determines prioritization of and how best to address the NPSG (TJC, 2017c). NPSGs have influenced safety and quality practices, such as correct patient identification, improved staff communication, safer medication administration, infection prevention, avoidance of confusing medical abbreviations, better equipment alarms, and measures to prevent surgical or procedural errors, including surgery at a wrong site or wrong patient.

Red Rules

Red rules is a term developed by non-health care industries to indicate safety rules that should never be broken, for example, taking steps to identify patients in every instance prior to commencing care. Health care organizations have adopted this premise along with the concept, a culture of safety. A culture of safety promotes attitudes, beliefs, perceptions, and values that an organization and its employees share to promote safety in the workplace. The red rules and culture of safety create a standard for care in which all, including associated physicians, adhere to measures for avoidance of error. Media exposure and the IOM 1999 report became the incentive to push for a culture of safety. Health care organizations urgently wished to avoid further patient safety events or sentinel events. TJC (2017b) terms an event not primarily related to the natural course of the patient’s illness or underlying condition apatient safety event. If a patient safety event results in death, permanent harm, or severe temporary harm and intervention required to sustain life, then the event becomes a sentinel event. TJC requires health care organizations to conduct a specific investigation, known as a root cause analysis (RCA), of every sentinel event. The RCA detects flaws in the caregiving system that failed to provide safety nets against patient harm. Such analyses have revealed points at which actions taken could avert harm and change the outcome. For example, at multiple points, a change in action could avoid the harm in cases of surgery on the wrong extremity, mishandling of laboratory specimens, surgery on the wrong person, instruments left in the body after surgery, and so on. Now commonplace, red rules include timeouts prior to any procedure, two forms of patient identification prior to any delivery of care, and bedside labeling for every patient specimen. Understanding RCA processes, in advance of patient safety events, helps a nurse be more safety conscious, prepared for beneficial documentation, and better equipped with information during the organization’s data gathering and interviewing process. TJC provided resources for understanding the process and expectations of a RCA (Parker, 2015).

Just culture, a safety culture concept, focuses on system issues that result in unsafe behaviors, yet holds individual employees accountable for avoiding reckless or risky behaviors and human error (Ulrich, 2017). As humans, nurses sometimes unknowingly make an error. Risky or at-risk behaviors are actions increasing the risk of error, such as taking a shortcut. The nurse accepts the risk, believing the risk is justified or that the outcome will be unaltered, yet error or a near miss may occur. Unfortunately, errors or near misses also occur when the person recklessly and deliberately chooses to ignore the scope of practice, practice standards, policies, and normal procedures. According to TJC (2017a), clear lines should be “drawn between human error and at-risk or reckless behaviors” (p. 2). In a 2010 position statement, the ANA indicates that a just culture does not assign personal blame for every error and does not hold persons singularly accountable for failures in the system (ANA, 2010b). Analysis of errors or near misses in just cultures includes the type of behavior associated with the error. The concept encourages employees to report all errors, near misses, and system difficulties, without fear of unfair blame and with the confidence of fair employer treatment (Paradiso & Sweeney, 2017). Awareness and analyses of the errors, near misses, and system difficulties allows the health care setting an opportunity to make changes that create safer, quality care environments for patients, families, and the organization.

Check for Understanding

1. What is the process in your workplace if you believe a sentinel event has occurred?
2. What barriers do you perceive to reporting a sentinel event in your workplace?
3. What support for reporting errors exists where you work?

Federal Legislation Influencing Health Care

Health and Insurance Portability and Accountability Act of 1996 (HIPAA)

In the 1990s, issues about access to personal medical information reached a national concern, especially because of the increasing use of technology, increased research, and personal information risks resulting from discoveries of genomic processes. The Health Insurance Portability and Accountability Act (HIPAA) established changes in the insurance industry, but especially important to nursing, created a law to be used in all health care settings holding personal medical information. Confidentiality, an ethical expectation, was now a federal law with guidelines for storing, accessing, and releasing personal health care information as “protected health information” whether the information is oral, written, or electronic. Individuals have protection from release of information that had personal identifiers. HIPAA Privacy and Security Rules developed as administrative regulations governing the protection of health information with disciplinary processes for violations. The threat of sanctions for violations of HIPAA was soon tested. In a landmark settlement, the U.S. government received $2.25 million from CVS Caremark Corporation for violating HIPAA privacy rules, such as patient information disposed in open dumpsters along with insurance information (Federal Trade Commission, 2009; U. S. Department of Health & Human Services, 2009).

The final modification to these privacy and security rules occurred in 2013. The final modification included expansion of the right of individuals to receive electronic copies of their health information and placed restrictions against disclosure to health plans for out of pocket treatments paid in full by the individual (Allen, 2013). The Genetic Nondiscrimination Act (GINA) prohibits health insurance plans from using or disclosing genetic information in determining coverage. The final 2013 modification of HIPAA applies GINA to those who fall under HIPAA rules (Allen, 2013).

Nurses can avoid HIPAA privacy violations by following some basic professional guidelines:

• Stop gossiping or face a serious fine. Do not share information with coworkers not related to the patient’s care. Sharing patient information should not occur with friends, family, and acquaintances.
• Be aware of location when speaking or whispering about a patient situation including hallways, cafeterias, and elevators. If answering a unit communication in another patient’s room, halt the conversation until in a secure area.
• Keep written information, such as charts, personal notations, or assignment sheets out of public view. Shred documents when finished.
• Use strong password protection and encryption of electronic and mobile devices that house patient information. Report lost and stolen devices promptly. Remember theft of protected health information from a stolen device can result in fines.
• Resist accessing patient information when not authorized as a caregiver.
• Do not mingle work and social media or text patient information. If working from home, keep screens out of view of family and friends and lock the computer when stepping away.
• Release information only with written authorization by the patient or legal guardian.

Remember, violations have consequences through the U.S. Department of Justice. The lowest penalty for knowingly obtaining and disclosing information comes with fines up to $50,000 and up to 1 year in prison (U. S. Department of Health & Human Services, 2013). The patient could file a civil suit as well. Consequences for violations involving wrongful conduct, false pretenses, selling or transferring identifiable health information, or malicious intent are higher with 5 to 10 years in prison and fines of $100,000 to $250,000 depending on the violation (U. S. Department of Health & Human Services, 2013). A violation can involve multiple parties (Cannon & Caldwell, 2016).

Affordable Care Act (ACA)

The controversial Patient Protection and Affordable Care Act (PPACA) is often abbreviated as the ACA. President Barack Obama signed the ACA into law in 2010, and the U.S. Supreme Court upheld the law as constitutional in 2012 (Deparle, 2012; Oberlander, 2012). The ACA featured provisions for health insurance and health system reform (U. S. Department of Health & Human Services, 2013). Insurance reform provisions targeted insurance coverage for more Americans, more insurance benefits and protections, and lower insurance costs for consumers and the government (American Public Health Association [APHA], 2012). Uninsured Americans would now have a pathway for affording health insurance. By March 2015, an estimated “16.4 million uninsured people had gained health insurance coverage as several of the Affordable Care Act’s coverage provisions took effect” (Office of the Assistant Secretary for Planning and Evaluation, 2015, p. 1).

Provisions to reform the health system pursued improved quality and effect, stronger workforce and health care infrastructure, and a greater focus on public health and prevention (APHA, 2012). Thus, the ACA turned health care upside down (see Figure 4.5). Health care formerly focused on providing care, but now the focus is managing health (Berg & Dickow, 2014). The change created a transformation in health care.

Figure 4.5

Transforming Health Care

Note. Adapted from “Nurse Role Exploration Project: The Affordable Care Act and New Nursing Roles,” by J. G. Berg and M. Dickow, 2014, Nurse Leader, 12, 40-44. Copyright 2014 by Nurse Leader.

According to Berg and Dickow (2014),

The emphasis on wellness and primary care in the transformed system under the ACA also promotes a definition of health that transcends the absence of disease to embrace social determinants of health, (including health behaviors such as tobacco use, diet, and exercise; social and economic factors such as education, income and family support; clinical care inclusive of access to care and quality; and the physical environment which considers things such as the quality of the air we breathe and the safety of our living conditions). (p. 41)

Specialty departments and services with isolation of information within the department usually drove health care before the ACA. After the ACA was implemented, health care now avoids siloed services, preferring instead patient-centered and outcome-driven, high-quality care. A care delivery model is known as an integrated practice unit (IPU) formed. Care structures around the medical condition with fully integrated care including treatment, education, counseling, and prevention. IPU achieves positive outcomes and lower expenses (Aoughsten, Johnson, Kuruvilla, & Bionat, 2015; Porter & Lee, 2013). Nurses have more opportunities for health promotion, leadership, and quality outcomes. For example, development or expansion of roles as nurse navigators, care coordinators, faculty team leaders, informatics specialists, community-centered nurses, and primary care partners (Berg & Dickow, 2014).

Availability of public information regarding the quality of health care increased with the transparency concepts of the ACA. The components of the ACA hold the government, health care providers, and health care organizations more accountable to deliver cost-efficient, quality care under this public scrutiny. The ACA includes multiple measures for health care quality, including the:

• National Quality Strategy (NQS) to lead all levels of government toward alignment with public and private payers for quality improvement strategies.
• Center for Quality Improvement and Safety to encourage evidence-based practice strategies for health care delivery.
• Patient-Centered Outcomes Research Institute (PCORI) enhancing informatics ability to generate patient-centered evidence for use in developing outcome measurements.
• Center for Medicare and Medicaid Innovation (CMMI) for inclusion of quality measurement and improvement in development and trials of new payment and delivery models.
• Physician Quality Reporting System (PQRS) for physician quality reporting of patient outcomes, perceptions, and timeliness of care, giving professionals an opportunity to evaluate performance. Those not participating are subject to reduced Medicare payment for services, known as a negative payment adjustment.
• Public Use Files (PFU) of state-based, competitive health insurance exchanges or marketplaces to provide a public report of the quality of health insurance plans.

Other features target health disparities by increasing data gathering on race, ethnicity, gender, socioeconomic status, and language. Having additional and better quality informatics regarding the diverse populations allows measures to reduce risks for health inequity. Culturally specific benefits directed to American Indians and Alaska Natives are an effort to reduce health inequities under the ACA. Authorization for new payment and care delivery models, focusing on quality, motivates new innovative approaches for health care organizations.

Under ACA mandates, health care providers must have a compliance program. Protection and prevention are primary goals of compliance programs. In health care, a provider’s formal program requires policies, procedures, and other internal processes designed to prevent and detect violations of federal and state laws. Preemptive and prompt detection of Medicare and other insurance fraud, waste, inefficiency, and abuse promotes safety for the health care organization, increases proper submission of claims, and reduces billing error. The compliance programs internalize promotion of patient safety and delivery of high-quality health care with more efficiency, less waste, and increased patient satisfaction. The nurse may participate in the formation of policies, procedures, and standards of conduct in an organization’s compliance program. The nurse demonstrates accountable and ethical behaviors, including cooperation with the compliance officer declared responsible for the program within the health care setting. Allegiance to the program policies may include whistleblowing on policy violations via reporting to a tip line or hotline. Nursing cooperation incorporates submission to education and training, prompt reporting of questionable practices, and responsiveness to the compliance officer’s investigations. Failure to respond and/or report can lead to disciplinary actions.

Human Subjects Research Protection

Autonomy, beneficence, and justice principles are at play when approaching potential participants and during the process of conducting research on human subjects. The federal government expects researchers to apply the highest ethical standards to protect any human subject (National Institute of Environmental Health Sciences, 2015; Domenech Rodríguez, Corralejo, Vouvalis, & Mirly, 2017). Congress passed legislation, effective January 2018, to update the federal law known as the Common Rule. Through mandates for ethical guidance and accountability, the Common Rule protects the rights, welfare, and well-being of human research participants. Nurses participating in research using human participants or biological specimens should familiarize themselves with the new law. Among the provisions adopted is a new rule requiring simpler informed consent forms to aid understanding for those who are trying to decide whether to participate as a research subject, as well as a reduction in the complexity of the information presented by placing key information in the beginning rather than buried within the consent form (Berkowitz, 2017; Menikoff, Kaneshiro, & Pritchard, 2017).

Health and Human Services and Information Technology (IT) Legislation

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act expanded the HIPAA Privacy and Security Rules. The act set goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes” (Gold & McLaughlin, 2016). The term meaningful use became the new jargon regarding the use of protected information. The aim was to increase electronic health record (EHR) adoptions for “more efficient, patient-centered health care system by lowering providers’ administrative costs, improving coordination of care among multiple providers, and increasing patients’ participation in and responsibility for their own care” (Galbraith, 2013, p.15). The U.S. Department of Health and Human Services’ goal was quality, safe EHR that were efficient to reduce health disparities, ease care coordination while maintaining privacy and security of patient health information. The Centers for Medicare & Medicaid Services implemented the “Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers” (Thurston, 2014, p. 510). Health care providers and organizations, if qualifying, received a financial incentive to transform the record creation and storing processes on an electronic basis. A key feature of the health information technology (HIT) was the interoperability of the EHR to maximize the use of EHRs as a tool for “efficient, effective, safe, and quality care” (Skiba, 2013, p. 356). A benefit for the public was increasing access to one’s health care record through secure electronic access. In addition, measures of the ACA reinforced the use of HIT and health information privacy requirements (U. S. Department of Health & Human Services, 2013).

Soon after the government established the Office of the National Coordinator for Health Information Technology in 2004, a grassroots nursing initiative began, now known as the TIGER initiative. The Technology Informatics Guiding Educational Reform (TIGER) Initiative focused on how to prepare nurses for the patient-focused HIT environment and created a Web-based learning platform for this purpose. The latter became the TIGER Virtual Learning Environment (VLE), which may be subscribed to by any health professional, faculty member, or student who wants “to learn and develop knowledge, skills, and awareness of technology and informatics” (Skiba, 2013, p. 356). Thus, nurse educators had a new resource for preparing nurses.

Taking Action and the World of Politics

What is the outlook for the professional nursing practice? Certainly, lifelong learning components urge the professional nurse to keep well informed of the Campaign for Nursing progress along with ongoing IOM reports, including progress toward increasing the number of BSN-prepared nurses. “The need for key stakeholders to provide leadership to take advantage of opportunities and overcome barriers has never been greater” (Berg & Dickow, 2014, p. 33). Leadership in the California Action Coalition urges nurses forward as “there is tremendous opportunity for nursing to lead important changes that are necessary to improve health for all residents in the state” (Berg & Dickow, 2014, p. 33). Involvement can be on the local, state, national, and global levels regarding emerging health care initiatives.

The world of politics is not one most nurses perceived as part of the job when entering a nursing program; however, health care requires increasing involvement from nurses on all political levels from the local to the global arenas. Nurse political participation could focus on a segment of the populations rather than a direct link to a health care setting. For example, Driscoll and Darcy (2015) studied legislation regulating adolescents’ use of tanning beds, noting no reduction in the rate of use. Along with educating patients and families, Driscoll and Darcy urge nursing activism “for legislation, enforcement of legislation, and public awareness of this global health issue. As advocates, nurses can have a direct impact upon the long-term goal of reducing the harmful effects of continued UVR exposure in this vulnerable population” (2015, p. 62).

Reflective Summary

Certainly, lifelong learning components urge the professional nurse to keep well informed of Campaign for Nursing progress along with ongoing IOM reports. All registered nurses are to become active players as barriers to nursing practice are removed, higher education is expected, and public demands for quality, safety, and health promotion increase. Nurses should incorporate the traits of critical thinking, clinical reasoning, and clinical judgment into all practice. Adherence to ethical principles, laws, scope and standards of practice, and safety goals are integral to safe and quality care. Laws are slow to change, but legislation shapes the current health care system. The nurse cannot sit on the sidelines of health care, but must act and incorporate political involvement into his or her practice.

Key Terms

Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into law by U.S. President Barack Obama and became known as Obamacare; among the provisions include health insurance coverage to uninsured, measures to lower costs and improve health care system efficiency, preventative care, extension of care to dependents under the age of 26, and prohibited insurance claim denial or higher premiums for preexisting conditions.

Analyticity: Utilization and application of evidence-based practice to perform patient care.

Applied Ethics: Various approaches to ethical dilemmas.

Autonomy: Free will to make own decisions about self and physical body.

Beneficence: Actively helping, doing kindness, performing quality conduct, and sharing goodness for the benefit of others.

Campaign for Action: Collaborative effort to implement the recommendations on nursing from the 2010 Institute of Medicine’s report The Future of Nursing: Leading Change, Transforming Health.

Clinical Judgment: “The outcomes of critical thinking in nursing practice. Clinical judgments begin with an end in mind. Judgments are about evidence, meaning and outcomes achieved” (AACN, 2008, p. v).

Clinical Reasoning: “The process used to assimilate information, analyze data, and make decisions regarding patient care” (AACN, 2008, p. v).

Confidence: Trust in one’s own capabilities.

Confidentiality: Keeping information secret from others; not disclosing private matters.

Compliance Program: Supervisory program to keep health care decision-making processes free of unethical influences and actions, identify fraud and abuse risks, promote adherence to laws, and require disclosure of accurate pricing information and truth in advertising.

Critical Thinking: “All or part of the process of questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity. Critical thinking underlies independent and interdependent decision making” (AACN, 2008, p. v).

Culture of Safety: Attitudes, beliefs, perceptions, and values that an organization and its employees share to promote safety in the workplace; organization-wide recognition of the risks in day-to-day activities with a resolve that all will employ safe practices consistently.

Ethical: Concepts and beliefs regarding right, good, law-abiding, honest, and respectable behaviors; regarding moral values.

Ethical Dilemma: Situations in which a difficult choice is required among options, none of which will resolve the situation in the most favorable ethical manner; moral value predicament.

Ethical Principles: Fundamental truths or foundational ethical values, assumptions, and beliefs

Fidelity: Loyalty; faithfulness to promises and duties.

Good Samaritan Law: State legislative protection against malpractice for those who provide emergency assistance to an injured person, in good faith (sincerity) and with reasonable care.

Health Disparity: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages..

Health and Insurance Portability and Accountability Act of 1996 (HIPAA): Signed into law by U.S. President Bill Clinton granting workers the ability to continue receiving health insurance coverage when changing or losing employment and yielding security and privacy standards for handling of patient health care information, including electronic transmissions.

Inquisitiveness: Curiosity for facts; thirst for knowledge; asking questions and researching answers. The nurse continually seeks new solutions and knowledge related to the given problem.

Institute of Medicine (IOM): A nonprofit organization affiliated with the National Academies of Science.

International Council of Nurses (ICN): An organization bringing together more than 130 nurses associations from various nations to advocate for quality in professional practice, health policies, and respect of the profession.

Integrated Practice Unit (IPU): A jointly accountable, multidisciplinary grouping of health care providers and staff that is organized around an individual’s health condition, providing comprehensive care for the full cycle of the condition and surrounding circumstances, incorporating direct contact, education, electronic communication, and follow-up.

Just Culture: Safety culture concept focusing on system issues that result in unsafe behaviors, yet holds the individual employee accountable to avoid reckless or risky behaviors and human error. Error or near miss analysis are based on the type of behavior associated with the error and not the severity of the event.

Justice: Fairness; impartiality; treating others the same.

Liable: Responsible or legally accountable; can be sued.

Malpractice: Negligent, illegal, or unethical professional action or omission that results in harm.

Meaningful Use: Government standard regarding the electronic exchange of patient information among health care providers, insurers, and patients for enhanced efficiency, safety, quantity, and quality of information sharing.

Metaethics: The nature of ethics and moral reasoning: right vs. wrong; good vs. evil; normative ethics which is the ethics of right and wrong in human action, addressing what we ought to do.

National Patient Safety Goals (NPSGs): Goals determined by The Joint Commission (TJC) specifically to improve the safety of patients; promotes and enforces major changes in safety measures for the recipient of health care.

National Practitioner Data Bank (NPDB): An ongoing storehouse of reports regarding medical malpractice payments and adverse actions by health care practitioners, providers, and suppliers, including adverse licensure issues.

Near Miss: A narrowly avoided error.

Negligence: Careless or improper behavior that results in damage.

Nurse Navigator: Person guided by evidence-based practice who helps patients understand the health care system; coordinates and transitions patient care through the system and into other systems.

Nonmaleficence: Committing no harm or evil; based on Hippocrates’s admonishment to first do no harm.

Open-Mindedness: The ability to be tolerant of opposing views and consider other perspectives and proposals.

Patient Safety Event: An event not primarily related to the natural course of the patient’s illness or underlying condition.

Police Power: Authority granted to the states by the 10th Amendment of the U.S. Constitution, allowing enactment of restrictive measures to preserve and protect order, safety, health, welfare, and morals of the public.

Privacy: Ability to keep personal matters to oneself or ability to be alone when desired and away from critical observation by others.

Respect: Treating every person as a worthy individual; honoring autonomy and protection for those with diminished autonomy.

Root Cause Analysis (RCA): Comprehensive systematic analysis designed to detect flaws in the caregiving system that failed to provide safety nets against patient harm; analysis to find the basis or causal factor(s) that resulted in a variation of performance.

Sentinel Event: A patient safety event, not related to the natural course of the patient’s illness or underlying condition, which results in death, permanent harm, or severe temporary harm and intervention required to sustain life.

Siloed: Separate and isolated process, department, or system from others.

Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.

Statutes: Laws passed by a state or the federal legislature; formal regulation.

Systematicity: Organized work process and flow.

The Joint Commission (TJC): Independent, nonprofit organization that conducts reviews for health care organization accreditation or program certification. TJC accreditation and certification represents a symbol of quality.

Technology Informatics Guiding Educational Reform (TIGER) Initiative: Effort focused on the readiness of nurses for the health information technology environment (HIT); created a Web-based learning platform for nurses learning HIT.

Tort Law: Law dedicated to remedies for harm caused by the unreasonable action, carelessness, or omission by others.

Veracity: Accuracy, honesty, truthfulness.

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