Priorities in Nursing Practice and Nursing Standards of Care

 Establishing Nursing Priorities

1. Prioritizing - decisions of which needs or problems require immediate attention or action and which ones could be delayed until a later time since they are not urgent.
2. Needs that are life-threatening or could result in harm to the client if left untreated are high priorities.
3. Actual problems or needs have higher priority than potential problems or needs.
4. Problems or needs identified by the client are of a higher priority.
5. Principles of Maslow's Hierarchy of Needs or the ABCs may guide decisions.
6. Mutual decision-making for priorities may be made with the client based on the client's needs, desires and safety.

NURSE PRACTICE ACTS

• Definition: passed by each state legislature to regulate the practice of nursing in that state
• Nurse Practice Acts define:
• Scope of Practice
• Education
• Licensure
• Professional Misconduct:
• Negligence
• The 'Impaired Nurse'
• The nurse who violates boundaries
• Administered by the Board of Nursing in each state:
• The nurse must know how their state defines professional misconduct
• For Professional Misconduct, the State Board of Nursing imposes penalties (in order of severity):
• On Probation
• Censured
• Reprimanded
• License Suspended
• License Revoked

STANDARDS OF NURSING PRACTICE AND STANDARD OF CARE

Republic Act 9173 or Philippine Nursing Act of 2002

AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES

Be it enacted by the Senate and the House of Representatives of the Philippines in Congress assembled: 

ARTICLE I: Title

• Section 1. Title 

• This Act shall be known as the "Philippine Nursing Act of 2002." 

ARTICLE II: Declaration of Policy

• Section 2. Declaration of Policy.

• It is hereby declared the policy of the State to assume responsibility for the protection and improvement of the nursing profession by instituting measures that will result in relevant nursing education, humane working conditions, better career prospects and a dignified existence for our nurses.
• The State hereby guarantees the delivery of quality basic health services through an adequate nursing personnel system throughout the country.

Board of Nursing Resolution No. 220 (2004)

PROMULGATION OF THE CODE OF ETHICS FOR REGISTERED NURSES

• Whereas, the Board of Nursing has the power to promulgate a Code of Ethics for Registered Nurses in coordination and consultation with the accredited professional organization (Sec. 9, (g), Art. III of RA 9173, known as "Philippine Nursing Act of 2002);
• Whereas, in the formulation of the Code of Ethics for Registered Nurses, the Code of Good Governance for the Professions in the Philippines was utilized as the principal basis therefore: All the principles under the said Code were adopted and integrated into the Code of Ethics as they apply to the nursing profession;
• Whereas, the promulgation of the said Code as a set of guidelines, regulations or measures shall be subject to approval by the Commission (Sec. 9, Article II of RA 9173); and
• Whereas, the Board, after consultation on October 23, 2003 at Iloilo City with the accredited professional organization of registered nurses, the Philippine Nurses Association, Inc. (PNA), and other affiliate organizations of Registered Nurses, decided to adopt a new Code of Ethics under the afore-mentioned new Law;
• Now, Therefore, the Board hereby resolved, as it now resolves, to promulgate the hereunder Code of Ethics for Registered Nurses.

Nurse and Contracts

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Contract

• Meeting of minds between two persons whereby one binds himself, with respect to the other, to give something or to render some service
• An agreement between two or more competent persons upon sufficient consideration to do or not do some lawful act
• Can be written or oral

Nurses and Crimes

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Crime

•  an act committed or omitted in violation of societal law and punishable by a fine and/or imprisonment or death
• Two elements:
1. Criminal act
2. Evil/Criminal intent

Legal Aspects and the Nurse

Professional Negligence

Negligence

• refers to the commission or omission of an act, pursuant to a duty , that a reasonably prudent person in the same or similar situation would or would not do, and acting or the non-acting of which is the proximate cause of injury to another person or his property

Elements of a Professional Negligence

1. Existence of a duty on the part of the person charged to use due care under circumstances
2. Failure to meet standard of due care
3. The foreseeability of harm resulting from failure to meet the standard
4. The fact that the breach of this standard resulted in an injury to the plaintiff

Nursing Jurisprudence

Nursing Jurisprudence

• Department of law which comprises all the legal rules and principles affecting the practice of nursing
• Includes the study and interpretation of rules and principles and their application in the regulation of the practice of nursing

Functions of Law of Nursing

• provides a framework for establishing what nursing actions in the care of patients are legal
• delineates the nurse's responsibilities from those of other professionals
• helps to establish the boundaries of independent nursing actions
• assists in maintaining a standard of nursing practice by making nurses accountable to the law

History of Nursing Law

Act No. 2493 (115)

• An act to amend No. 310 regulating the practice of medicine in the Philippines
• Provided for the examination and registration of nurses
• Nurses must apply for registration to the Director of Health
• Requirements: Good moral character, good health and 21 years old

Act No. 2808 (1919)

• An act regulating practice of nursing profession
• the first "True Nursing Law"
• created the board of examiners composed of 3 members
• Examination date on the 2nd Monday of June and December
• First board exam: 10920

Act No. 3025 (1922)

• Amplification of the definition of the nursing profession
• Granting the privilege of registering as nurses without exams the Registered Nurses from the United States
• Change the date of exam: 2nd Monday of April and October

Act No. 4007 (1932)

• Reorganization law of 1932
• Conduct of examination was placed under the direct supervision of Bureau of Civil Service
• Change of jurisdiction over the Board of Examiner under the Department of Public Instruction

Executive Order No. 317 (1941)

• Pursuant to Commonwealth Act 430, transfer of jurisdiction of the board to the Department of Health and Public Welfare

Republic Act No. 546 (1953)

• Organization of the Board of Examiners of nurses
• Provisions regarding nursing schools and colleges, examinations, registration of nurses including sundry provisions relative to the practice of nursing
• Two important sections pertained to the need for registration as nurse before anyone could practice nursing in the country
1. No person shall practice or offer to practice nursing in the Philippines as defined in the Act, without holding a valid certificate of registration as nurse issued by the Board of Examiners for Nurses
2. Not only prohibit the practice of nursing without a certificate of registration issued by the Board of Nursing but also provides the penalty for doing so

Republic Act 4704 (1966)

• Amended certain portions of Republic Act 877
• The membership of the Board of Examiners for nurses was increased 3 to 5 members
• Members of the Board were to be appointed by the President of the Philippines with the consent of the Commission on Appointments and no longer upon the recommendation of the Commission of Civil Service
• The requisite academic degree for members of the Board was a Master's Degree instead of Baccalaureate Degree in Nursing
• No person was eligible for membership in the board if he/she was over 65 years of age
• The academic qualification for Dean, Directors and Principals of colleges and schools of nursing was raised to that of Master's Degree in Nursing
• The minimum age required of applicants for admission to the nurse's examination was lowered from 21 to 18 years of age, but no candidate who passed the examination was permitted to practice the profession until he/she reached the age of 21 years

Republic Act 6136 (1970)

• The application and execution of legal orders in writing of physicians concerning treatments and medications including the application of hypodermic and intramuscular injection; provided that intravenous and other injection may be administered under the direction and in the presence of the said physician

Republic Act 7164 or the "Philippine Nursing Act of 1991

• Redefinition of the scope of nursing practice to emphasize
1. The use of nursing process as a scientific discipline in arriving at an appropriate nursing action and care
2. The teaching, management, leadership and decision making roles of the nurse
3. The undertaking of and participation in studies and research by nurses
• Requiring a faculty member who was appointed to the Board of Nursing to resign from his/her teaching position at the time of appointment and not one year preceding his/her appointment as provided in Republic Act 877
• Updating a faculty's educational qualification by requiring a Master's Degree in Nursing or related fields or its equivalent in terms of experience and specification as pre-requisite to teaching
• Specification of qualifications of administrators of nursing services
• Inclusion of the phrase "unethical conduct" as one of the reasons for revocation and suspension of certificate of registration

Republic Act 9173 or the "Philippine Nursing Act of 2002"

• The Board is now composed of a Chairman and 6 members instead of a Chairman and 4 members
• Submission of names of qualified nominees by the Accredited Professional Organization (APO) to the Commission, three (3) nominees per vacancy, not later than three months before the vacancy
• The Commission submits to the Office of the President two (2) nominees per vacancy not later than two months before the vacancy occurs. The appointment must be issued not later than thirty (30) days before scheduled licensure examination
• Qualifications of Board Members
1. Educational requirement for members of the Board is not limited to registered nurses with Master's Degree in nursing but also to registered nurses with master's degrees in education, or other allied medical profession provided that the Chairperson and majority of the members are holders of a Master's degree in nursing
2. Of the ten years of continuous practice of the profession prior to appointment, the last five (5) years must be in the Philippines
• Added the powers and duties of the Board
1. Adopt and regulate a Code of Ethics and Code of Technical Standards for the practice of nursing within one year from the effectivity of this act
2. Recognize specialty organization in coordination with accredited professional organization
• Licensure Examination and Registration
1. Specific age of applicants has been deleted
2. Specific dates of examination has been deleted
• Specific dates of examination - not earlier than one (1) month and not later than 2 months after the closing of each semestral term
• Ratings
1. Specific number of times an examinee may take the licensure examination has been deleted
2. Added: removal examination shall be taken within two (2) years after the last failed examination
• Revocation and Suspension of Certificate of Registration
1. Added: Implementing Rules and Regulations, Code of Ethics, Code of Technical Standards, for nursing practice and policies of the Board and the Commission
2. Added: Section 28 for practicing the profession during the period of suspension
3. Period of Suspension of the certificate of registration/professional license not to exceed four (4) years
• Nursing Education
1. Added: requirement for inactive nurses returning to practice - nurse who have not actively practiced the profession shall undergo one (1) month of didactic training and three (3) months of practicum
2. Qualifications of Faculty - requirement of clinical experience in a field of specialization has been reduced from three (3) years to one (1) year in a field of specialization
3. The Dean of the College of Nursing must have at least five (5) years of experience in teaching and supervising a nursing education program
• Nursing Practice
1. Scope of Nursing - Duties and responsibilities of the nurse
• Deleted: special training for intravenous injections but Nursing Service Administrators still require formal training for the safety of the patient and the protection of the nurse and of the institution
• Added: special training for suturing the lacerated perineum. (Note: This is being undertaken by the Association of Nursing Service Administrators of the Philippines (ANSAP) with the Maternal and Child Association of the Philippines (MCNAP))
• Added: observe the Code of Ethics and the Code of Technical Standards maintain competence through continual professional education
• Health human resource production and utilization additions
• Comprehensive Nursing Specialty Program
1. The Board is mandated to formulate and develop a comprehensive nursing specialty program that would upgrade the level of skills and competency of specialty nurse clinicians in the country
• Salary. Minimum base pay of nurses in public health institutions shall not be lower than the first step or hiring rate prescribed for Salary Grade 15 pursuant to Republic Act 6758, otherwise known as Compensation and Classification Act of 1989
• Funding for the comprehensive Nursing Specialty Program. The annual financial requirements to rain at least ten (10) percent of the nursing staff of the participating hospital shall be chargeable against the incomes of the Philippine Charity Sweepstakes
• Incentives and Benefits. Incentives and benefits shall be limited to non-cash benefits such as free hospital care for nurses and their dependents and scholarship grants
• Penal and Miscellaneous Provisions
• Penalty for violation of this Act in fines has been increased to not less than fifty thousand pesos (P50,000) not more than one hundred thousand pesos (P100,000)
• Imprisonment of not less than one (1) year nor more than six (6) years or both fine and imprisonment upon the discretion of the Board

COMPREHENSIVE NURSING SPECIALTY PROGRAM

• Nursing Specialty Certification Program has been adopted and a Nursing Specialty Certification Council has been created on the basis of Republic Act No. 7164
• It was done through Resolution No. 14 of the Board of Nursing on February 18, 1999
• The adoption and creation were perceived to oversee the administration of the program by the Specialty Certification Board
• These Specialty Certification Boards were scheduled for creation in each of the four major groups of nursing specialties with the assistance of the Clinical Nurse Association of the Philippines Inc.
• The purpose of this program is to upgrade the level of skill and competence of specialty nurse clinicians in the country

Resolution No. 14 

• contained developments that served as premises and justifications for its issuance
• includes:
1. increasing emphasis on the climate for specialization - advances in science and technology direct initiatives toward high quality performance in a field of choice
2. emergence of the concept of globalization - as imposed by the national laws of countries all over the world, this facilitates the removal of barriers in trade, industry and services
3. response to increasing demands of developments - impels people in the service sector to address the challenges imposed by changes resulting from advancement and innovations in facilities and strategies of healthcare delivery
4. adoption of a system of incentives and benefits - recognizes individual and collective efforts as a process in inspiring nurses and other stakeholders toward preparing practitioners to acquire expertise in delivering service to their clientele
5. current trend of specialization in nursing practice recognized by the International Council of Nurses - the deepening and refining of nursing practice and applying it to the Philippine setting enhances the quality of nursing care and consequently benefits the Filipino clientele
6. the need for a framework of the program, and detailing the mechanics, guidelines and procedures for its implementation - the consultation of the Board of Nursing with the leaders of national nursing association and other concerned nursing groups led to the decision of tasking a special group of nurses to study and prepare a position paper that captures the process of implementing the Nursing Specialty Certification Program. As a consequence, resolution no. 14, series of 1999, details the mechanics, guidelines and procedures for its implementation
• the scope of Resolution 14 is covered in the following headings:
1. the framework
2. definition
3. assumption
4. nursing specialty certification council
• the term, Specialty Certification, in the Resolution is defined in three (3) perspectives:
1. a process
2. as a mechanism
3. as an act
• Special Certification
1. the process whereby qualified agents based on a variety of measures and assessment strategies, confirm or attest that individual nurses who underwent training and instruction for advanced nursing practice in specialized nursing services meet minimum standards set at specified times
2. It is a mechanism that is used to validate achievement of a level of clinical specialty of functional expertise and competence that goes beyond the level of basic licensure
3. the act of a competent authority, embodied in a document certifying that one has fulfilled the requirements of and may practice in a particular level and field of specialization
• Nursing Specialty Certification Council is described in Resolution No. 14 under nine (9) sub-topics, including:
1. Mission
2. Commitment of the Board of Nursing
3. Function of the Nursing Specialty Certification Council
4. Creation of the Sub-specialty Boards
5. Organizational structure
6. Creation of the Appeals panel
7. Creation of the Specialty Certification Board
8. Formulation of the criteria for the selection and qualifications of committee members
9. Levels of certification
• The three (3) levels subject to certification are:
1. Level 1 - Nurse Clinician
2. Level 2 - Nurse Clinician II
3. Level 3 - Clinical Nurse Specialist

Client/Patient Rights

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I. Privacy

• Confidential information may only be released by signed consent of the client
• Unauthorized release of client data may be an invasion of privacy
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides clients with access to their medical records and more control over how their personal health information is used. Provides privacy protection for consumers of health care.
• You must release information when a court orders, or when statutes require it (as in child abuse or communicable diseases)
• Special regulations apply to release of information about psychiatric illness or HIV

II. Advance Directives (ADs)

• As part of the Omnibus Budget Reconcilliation Act (OBRA), congress established the Patient Self-Determination Act:
• requiring every Health Care Facility receiving Medicare and Medicaid funds to provide written information to adult clients outlining their rights to make health care decisions

OMNIBUS BUDGET RECONCILLIATION ACT of 1990 (OBRA)

• requires that states provide advanced directives as options for clients
• Advance Directives:

1. Document that allows clients to make legal decisions about how they wish to receive future medical treatment
2. May indicate who the client wishes to make medical decisions in situations in which the client is unable to do so
3. Needs to be signed and witnessed and copies kept on file in the physician's office and the hospital
4. Implementation varies among states. In many states the witness to this document should not be a hospital employee, relative or heir to the client's estate. Medical social workers are usually acceptable as witnesses in many states.

• Rights include:
1. right to refuse or accept treatment
2. right to formulate advance directives
• Nurses and other members of the health care team are required to:
1. assess the client's knowledge of advance directives and their status regarding the advance directives process
2. provide information and assistance to the client in developing advance directives
3. plan care that incorporates the client's decisions regarding advance directives
• Three common advance directives are:
• Living Will
• living will indicates the client's wishes regarding:
1. prolonging life using life support measures
2. refusing or stopping medical interventions
3. making decisions about their medical care
• living will is executed while the client is competent and able to make sound decisions
• as conditions change, a living will needs to be reevaluated for relevance
• living wills may differ as based on state laws
• Durable Power of Attorney for Health Care Decisions
• legal document allowing the client to name an adult to act as a personal advocate and make health care decisions if the client becomes incompetent
• can be used to accept or refuse treatment
• in the absence of a living will or a durable power of attorney the health care providers often turn to the family members
• however, in many states a family member does not have the legal authority to make health care decisions unless they are legally appointed guardians or parents
• Do Not Resuscitate (DNR) Status
• follow the facility policy on obtaining and implementing DNR orders
• generally the order must be written by a physician, some facilities may have a policy to allow verbal orders under specific conditions
• the order must be communicated clearly to all personnel caring for the client
• the client or their health care proxy can withdraw the order at any time
• a nurse who attempts to resuscitate a client with a valid DNR order may be committing battery

III. Refusal of Treatment - competent clients may refuse treatment, even life-sustaining treatment

IV. Freedom from Safety Devices/Restraints

• Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraints/safety device and a time limit
• Types of restraints/safety devices

1. chemical
2. physical

• Use the least restrictive form of restraint/safety device
• Know agency guidelines for use of restraints/safety devices
• You must document three factors:

1. why you used restraints/safety devices
2. how the client responded
3. whether the client needs continued restraints/safety devices

• Restraining clients without consent or sufficient justification may be interpreted as false imprisonment

GUIDELINES FOR SAFETY DEVICES

• Health care providers can legally restrain a client under certain conditions defined by the law and by the health care facility's policies and procedures
• The safety devices/restraints must be necessary to meet the client's therapeutic needs or to ensure the safety of the client or others
• The least restrictive type of safety device/restraint must be used first
• Use of safety devices/restraints must be accompanied by the health care provider's orders except in emergency
• The client must be closely monitored when in safety devices/restraints
• Safety devices/restraints should be released periodically and the skin integrity of the area checked for breakdown
• Document all pertinent details including why the safety devices/restraints are being used and client's response
• Make sure that the orders for safety devices/restraints are written and updated according to the policy of the facility; more commonly every 24 to 48 hours

V. Informed Consent

• Mentally competent adult client must give his/her own consent; parents or legal guardians may give consent for minors
• Clients need to understand:

1. Purpose of the procedure
2. Any reasonable alternatives
3. Risks, consequences and benefits of the procedure and the alternatives
4. Risks and consequences if the treatment is refused

• The physician caregiver has the legal obligation of obtaining a client's informed consent to medical/surgical treatment
• The nurse may be assigned the task of obtaining and witnessing the client's signature
• The nurse who is concerned about the validity of an informed consent has a legal obligation of telling the physician and the nursing supervisor about the concern
• Basic Requirements

1. Capacity
2. Voluntarism
3. Information

• The client must understand:

1. purpose of the procedure and expected results
2. anticipated risks and discomforts
3. potential benefits
4. any reasonable alternatives
5. that client may withdraw consent at any time

• The care provider has the legal obligation to obtain informed consent for medical treatment but the nurse should confirm the consent and answer the client's questions

VI. Transition Planning

• recognizes that clients are not discharged from care but moved across the continuum to another level

Professional Misconduct

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I. The Impaired Professional

• Remember that the impaired nurse is compromising client care
• Be sure that the problem exists and can be proven
• Communicate specific concerns to appropriate persons such nurse manager or risk manager
• Document incidents in terms of behaviors, specific times, dates - be objective
• File a report according to the policies and procedures of the institution

II. Boundary Violations

• Definition - actions that overstep established interpersonal boundaries to meet the needs of the nurse
• Guiding principles in determining professional boundaries

1. Nurse is responsible for setting and keeping boundaries
2. Nurse must avoid simultaneous professional and personal relationship with a client
3. Nurse must avoid flirtation

Legal Responsibilities

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I. Definition - legally, a breach of the duty to provide nursing care to the client. A form of malpractice. The unintentional failure of an individual to perform or not to perform an act that a reasonable person would or would not perform in a similar set of circumstances. Malpractice is professional negligence.


II. Negligence involves four legal concepts

• Duty - nurses have a legal obligation to provide nursing care to clients

1. Must meet a reasonable and prudent standard of care under the circumstances
2. Must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances

• Breach of Duty - failure to provide expected, reasonable standard of care under the circumstances (include errors of omission or commission)
• Proximate cause:

1. Relationship between the breach of duty and the resulting injury
2. The injured party must prove that the nurse's action or omission led to the injury

• Damages - the injury and the monetary award to the plaintiff

1. Example: Mr. X sues Nurse Jones for negligence. Mr. X must prove that Nurse Jones committed a breach of duty and that the breach of duty was the proximate cause of Mr. X's damages

Nurse Practice Acts

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I. Definition - passed by each state legislature to regulate the practice of nursing in that state
II. Nurse practice acts define:

• Scope of practice
• Education
• Licensure
• Professional misconduct

1. Negligence
2. the Impaired Nurse
3. the Nurse who violates boundaries

III. Administered by the Board of Nursing in each state:

• The nurses must know how their state defines professional misconduct
• For professional misconduct, the state board of nursing imposes penalties (in order of severity)

1. On probation
2. Censured
3. Reprimanded
4. License suspended
5. License revoked

Establishing Priorities

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I. Prioritizing

• decisions of which needs or problems require immediate attention or action and which ones could be delayed until a later time since they are not urgent
• needs that are life-threatening or could result in harm to the client if left untreated are high priorities
• Actual problems/needs have higher priority than potential problems/needs
• Problems/needs identified by client are of a higher priority
• Principles of Maslow or the ABCs may guide decisions
• Mutual decision-making for priorities may be made with the client based on the client's needs, desires and safety

Documentation

I. Key Aspect of Effective Documentation


LEGAL GUIDELINES FOR CHARTING

• Record the facts legibly, in ink
• Never erase, scratch out, or apply correction fluid. Cross through an error once, date and initial the change
• Do not leave blank spaces in your nursing notes
• Never chart for another person
• Avoid interpreting patient statement. Record exactly what the patient said in quotations marks
• Correct all errors in a timely manner
• Chart in a timely manner

COMPUTERIZED CHARTING

• Never lend access ID to another person
• Maintain confidentiality of documented information printed from the computer

II. Types of Documentation

• Problem-oriented medical record (POMR)
• Narrative documentation
• Focus charting
• Charting by exception

III. Documentation Guidelines

• General

1. Check that you have the correct chart
2. Altering a client chart is a criminal offense
3. Document enough information to describe the situation accurately

• Computerized

1. Use the user ID code, name or password
2. Do not tell anyone your password
3. Carefully check your information before you press enter
4. Log off when you are finished
5. Do not let clients observe other's information on the computer screen
6. Maintain privacy and confidentiality of documented information printed from the computer

• Paper-Ink

1. Use permanent ink of color according to agency policy
2. Use agency policies for error correction (usually one line drawn through the error, initial and date) and late entries
3. Do not document for others or change documentation for others
4. Include consent for or refusal of treatment, client responses to interventions, calls made to other health care professionals
5. Write legibly
6. Use only organization approved abbreviations
7. Chart the time and date for each entry