The Legal and Ethical Aspect of Nursing

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In today's modern society, healthcare professionals can and should assume a strategic position to help shape the contours of the healthcare environment in a way that it embraces and protects essential social values. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A person's values influence beliefs about human needs, health, and illness, the practice of health behaviors and human responses to illness. An individual are not born with values, rather values are formed during a lifetime from information from the family, culture and environment.

According to Purtilo (2005), values are the freely chosen principles, ideas, or standards held by an individual, class, or group that give meaning and directions to life:

Value is the language that has evolved to talk about objects or things a person holds

dear. An apt example is life itself. Without it you can not do anything else. Many moral

values build on this basic value of life and describe certain qualities that constitute "a

good life" from the perspective of how individuals can live full lives, finding support for

their basic interests and providing it to others. (p.8)

In our modern society much of the morality of the health professions is embedded in customs, policies and practices of health care institutions. Many professional associations have been formed to promote the improvement of the nursing profession. One of the well known professional associations is the American Nurses Association (ANA).

ANA became a broad association with a large spectrum of purposes. It consists of more than 54 nurses associations. The main purpose of ANA is to attain a high quality healthcare, by improving health standards and facilitating availability of health care services for the population. ANA places high importance for continuing education for nurses, supporting not only their professional development, but their general and economic welfare, too. In order to achieve its goals, ANA continues to assure that ethics and human rights are addressed in healthcare policy, by preparing position statements related to end-of -life care. It focuses in practice standards for more than 25 nursing specialties; advocates on behalf of all advanced practice registered nurses (APRNs) for a future oriented model of APRN regulations; and last but not least, ANA works to expand governmental support of nursing and quality patient care at the federal and state level.

The ANA's 2004 Scope and Standards of Nursing Practice defines the activities of nurses that are specific and unique to nursing. The standards allow nurses to carry out professional roles, serving as for the nurse, the patient, as well the institution. According to Taylor et. al. (2008) "Each nurse is accountable for his or her own quality of practice and is responsible for the use of these standards to ensure knowledgeable, safe, and comprehensive nursing care" (p.20). The Nurse Practice Act is a series of laws that regulate the practice of nursing. They vary among states, but have the common feature of protecting the public, creating a state board of nursing that have the authority to make and enforce rules and regulations concerning the nursing profession, as well as establishing criteria for education and licensure for nurses.

The American Nursing Association (ANA) has a special interest in providing the best patient care possible in order to obtain good outcomes. They initiated some indicators referring to patient safety and effective care of the patient that is affecting positively the healthcare reform

By working extended hours, nurses tend to get fatigued, thus affecting the outcome and quality of the care provided to their patients. Researches and studies were performed referring to this issue, and therefore policies were made that regulates the extent of time a nurse can work continuously:

ANA supports legislation that seeks to limit the number of hours a nurse can be forced to

work to 12 hours in a 24-hour period and 80 hours in a 14-day period. Improving the

work environment ultimately rests on nurse staffing levels that are based on the

development and assessment of staffing systems that will determine safe and appropriate

staffing levels and skill mix that are linked to patient outcomes. (American Nurses

Association, 2002)

Due to the nursing shortage, maintaining a stable registered nurse workforce will require the

political, legislative and policy focus to implement and maintain strategies related to the

supply, education, distribution and utilization of nurses over the long term. For example, as a

strategy to maintain existing nursing resources, ANA recommends full funding for financial

grants established under the Nurse Reinvestment Act to encourage health care facilities to

implement the Magnet concept (Glazer, G., Doheny, M., Geolot, D. (2004). The Magnet program

recognizes a workplace that fosters nursing excellence and supports professional practice.

In order to have well prepared staffing, to help achieve high standards in patient

satisfaction, states should be encouraged to allocate funding to state-sponsored schools ,

employers should consider establishing programs that allow for paid time off for practicing

nurses pursuing formal, degree-earning education. Tuition reimbursement programs should

be offered by the employers.

Our daily nursing practice is based on ANA's Standards of Practice, since we are collecting comprehensive data that is pertinent to our patients' health, analyzing these data in order to determine a nursing diagnosis for the patient. On a daily bases we are identifying expected outcomes for a plan that is individualized for our patients, identifying a plan of care, while coordinating care delivery and employing strategies to promote health. By identifying and analyzing the best available scientific evidence, we nurses are developing further guidelines for clinical practice. For example, at my workplace we are recognizing the importance of early nutrition of the patients after various surgical interventions, as this reduces the risks of acquired pressure ulcers and other skin impairment during hospitalization.

ANA's Code of Ethics for nursing represents an ethical standard for all practicing Nurses. The Code of Conduct provides guidance for nursing students. Also ANA's position statement regarding the direct relationship between patient-staffing ratio and quality of care, contributes to regulations related to the ratio of patients and caregivers. A clear example regarding this aspect is that beginning 2009, at the Cleveland Clinic was implemented a team-group project, meaning that a group of one registered nurse (RN) , one license practical nurse (LPN) and one patient care nursing assistant (PCNA) care for a maximum of seven patients.

The Ohio Nurse Practice Act is a document containing laws and rules written by the Ohio

Board of Nursing, used as criteria that an applicant must meet in order to be eligible to sit for the

examination for licensure to practice nursing as a registered nurse or licensed practical nurse to define the standards for educational nursing programs and approve continuing education or

renewal of license (Ohio Nurse Practice Act, 2001, Board of nursing-powers and duties 4723.06). Any person who wants to practice nursing, as a registered nurse or as a licensed practical nurse, in Ohio needs to follow the laws and the rules in this document, and have a current and valid license approved by the Ohio Board of Nursing (Ohio Board of Nursing, 2001). The Board may revoke the license or may refuse to grant the license if an individual is found to have committed fraud, misrepresentation or deception in passing, applying or securing any

nursing license. Other reasons why the Board may decide to deny, suspend or place restrictions on a nursing license include: failure to renew the license; practice of nursing when the license is suspended; convicted or plea guilty to a juridical finding; self administration of any drugs without a valid prescription; use of uncontrolled substances; inability to practice safe nursing care; assaulting or harming a patient; obtaining anything of value in the course of practice; engaging in activities that exceed the practice of nursing; failure to maintain professional boundaries with a patient (Ohio Board of Nursing, 2009).

Aligning to the Ohio Board of Nursing's (OBN) requirements, we nurse must renew our professional licenses every two years. In order to do this we have to fulfill the 24 hours of continuing education requirement. This is a mandatory requirement that also assists with maintaining the nurses' educational level and improving their knowledge base as well as their technical skills.

The hospital where I work is one of the well known Magnet hospitals of the United States (U.S.). There is an ethics committee at my work place that ensures the provision of ethical and quality care for all our patients. The Ethics Committee at my workplace comprises members of medical staffing: physicians, nurses, administrators, clergy, social workers, lawyers, and representatives of quality management. Patients and staff can access the Ethics Committee via phone. This can be called during the week hours and appointments can be made this way. It is needed to fill out a request form, that comprises aspects of the issues involved, and then investigations are made, interviewing the involved people. Reports of any findings or recommendations from the Ethics Committee are forwarded to the Board of Governors for action. The Ethics Committee can be easily located on the hospital's intranet site, where specific features of the committee as well as contact information are disclosed to anyone interested. Phone numbers to contact, are also posted in the hospital's phone directory. Representatives from family liaison are also visiting patients and offering their business cards that have the contact numbers listed, thus ensuring that the patients or their families have an extra professional that they can rely on when support is needed.

Employees at the Cleveland Clinic Foundation (CCF) are encouraged to continue their education to become better professionals. They can benefit from the tuition reimbursement program offered by CCF to support educational expenses and facilitate advancing in carrier.

Since our population is more culturally diverse, as a nurse I commit myself to secure the best possible care for patients from different cultures, being respectful of their beliefs and preferences, but without violating the practice of good nursing. Just like Chitty and Black (2005) emphasized, effective nurses will be more culturally competent: "Nurses will continue to provide a warm, humanizing influence on patient care in potentially dehumanizing high-tech

environment." (p. 441). At my workplace we expanded our focus on becoming more culturally competent. As a result we developed a communication tool that is available on-line for all health care professionals to assist with communication with patients belonging to cultural backgrounds different than our own, thus language barrier will be eliminated and will no longer constitute a barrier in reaching the best health care outcome for our culturally diverse patient population.

In all our nursing activities the main focus is our patient's well being, safety and satisfaction with the care provided. To reinforce safe nursing practices we are audited at a daily bases on our daily documentation, restraint use, intravenous line assessments and documentation, medication administration, skin documentation and pressure ulcer documentation. In addition to this we are educated on a weekly basis regarding new policies or standards of practices that we need to comply with. Educational offerings are also advertized by our management team as well the nursing education team. We are encouraged to improve our knowledge base by attending the upcoming Neuroscience Conference as well as the Stroke Conference. To improve our skills related to the advanced technologies regarding electronic charting we had to attend mandatory Epic-update classes. To increase the nursing staff's familiarity with the newest dialysis machines the clinic acquisitioned, we had to take mandatory in-services. In order to maintain our familiarity with the Ohio Nursing Law, we have to take the mandatory law quiz that is added to our Comet Competencies. Since one important focus is placed on patient satisfaction, the CCF mandates its entire personnel to attend the "Experiencing CCF" classes, to educate nurses regarding tools to use to improve nurse-patient relationship and to achieve the best healthcare outcomes possible. In order to keep track of errors or weaknesses of the system that might have negative effects on the patient care outcome, we have available the electronic incident report system called "SERS report", where concerning situations can be reported, the entered data is analyzed and when is the case, adjustments in the present policies are made in order to attain the best and safest care offered to our patients.

In conclusion, we, nurses must explore our own commitment to the nursing profession and realize that every one of us can become world changers if we strive for excellence in nursing. ANA and the State laws are offering the main guidance for our professional activity, helping to reach and maintain the Magnet status that we all should strive for.