Fields of Nursing

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Institutional Nursing (Hospital Nursing)

• Wide range of specialization and areas of work (OB, Trauma, Surgery, Internal Medicine, Nuclear, Recovery Room, Critical Care, etc.)

Public Health Nurse

• Main concern is prevention of diseases, promotion of health and vigor of the people in the rural areas (Clinics, RHU, Communities, Mobile Clinics, Diagnostic Centers)

Industrial Nursing

• Looks after the health of the employees
• Function is to maintain a high standard of nursing service in the company, interpret, develop and administer the health programs emanating from the health unit

Republic Act 1054

• requires employment of nurse in a commercial, industrial or agricultural establishment having employee not less than 30 or not more than 200 permanent employees and laborers (but the main duty is mainly to take charge of the emergency medicines for use of the employees)

Special Employment

• employment of nurses on certain vessels
• required by law
• (Republic Act 10 as amended by Republic Act 233) no such vessels with a carrying capacity of 75 passengers or more but less than 150, regularly making voyages lasting more than 24 hours without touching port, any lawfully sail from any Philippine port unless it has a  male nurse in its complement
• To be enforced by bureau of customs
• Penalty - not more than 1000 or not more than 2 years of imprisonment

Military Nursing

Brief History

• National Defense Act - 1940 (Commonwealth Act No. 386)
• Under this law, the Army Nurse Corps was created as component of the medical service of the Philippine Army
• Later the name was changed to Nurse Corps
• Qualifications
1. Single
2. Female
3. Bachelor of Science in Nursing graduate
4. Registered Nurse
5. 21-26 years old
6. Regular or reserve

Nursing Education

• the career leader in nursing education starts with a Clinical Instructor's position up to the Dean of a College of Nursing

School Health Nursing

• must like children a lot
• often work alone, out of touch with other nurses, the hospital and all professional supports they have known
• responsible for the school's activities in the areas of health service, health education and environmental health and safety

Private Duty Nursing

• expected to be expert clinicians as well as expert generalist in nursing
• renders comprehensive nursing care to a client on a one-to-one ratio
• an independent contractor
• patient may be provided care in the hospital or in the home

Clinic Nursing

• requires that nurse possess general skills
• usually a doctor has been in general practice for a number of years - with him, nurse acts as a receptionist, answers phone, does the billing, takes x-rays and ECGs, changes dressing, gives injections and assist in physical examinations
• may do autoclaving of instruments, keep records, order and store supplies, make follow up calls and referrals for patients

Professional Nursing

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Professional Nursing - the performance for a fee, salary or other reward or compensation of professional services

• Undertaking responsible nursing care and supervision of patients involving the whole management of care, requiring or application of principles of the biologic, physical and behavioral sciences
• Observation of the signs of physical as well as mental conditions and needs requiring evaluation or application of principles of biologic, physical and behavioral sciences
• Accurate reporting and recording of facts including evaluation of the whole case
• Supervision of others contributing to nursing care of patients
• Execution of nursing procedures and techniques
• Direction and education to secure physical mental care
• Application and execution of legal orders in writing of physician's orders concerning treatment and medication

Determinants of Professional Practice

• Problems and needs of the people
• Policies and regulations
• Current socio-economic-political and cultural systems

Levels of Care of Nursing Practice

• Promotion of Health
• Prevention of Illness
• Restoration of Health
• Consolation of Dying

NURSING FUNCTIONS

• Independent Functions

1. Involve actions which the nurse initiates herself
2. Autonomous actions based on scientific rationale that is executed to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals
3. Can solve client's problems without consultation to other health care professionals
4. E.g. Health teachings

• Dependent Functions

1. Based on the physician's response to a medical diagnosis
2. The nurse intervenes by carrying out physician's written orders, but requires nursing judgment or decision making
3. E.g. Administration of medications

• Interdependent or Collaborative

1. Therapies that require the knowledge, skill and expertise of multiple health care professionals

CLASSIFICATION OF NURSES

• According to types of position held
1. Administrator or administrative assistant
2. Consultant
3. Supervisor or assistant supervisor
4. Professor, lecturer or instructor
5. Dean or college secretary
6. Head nurse or assistant head nurse
7. Chief nurse
8. General duty nurse or staff nurse
• According to Professional Status

1. Active
2. Inactive

• According to Types of Duty

1. General duty nurses
2. Private duty nurses

• According to the Fields of Nursing where they Devote their Practice

1. Hospital or institutional nurse
2. Public health nurses
3. Nurse educators

Roles and Functions of the Nurse

• Care Provider.  The nurse supports the client by attitudes and actions that show concern for client welfare and acceptance of the client as a person. The nurse is primarily concerned with the client's needs
• Communicator. The nurse communicates with clients, support persons and colleagues to facilitate all nursing actions
• Teacher.  The nurse provides health teaching to effect behavior change which focuses on acquiring new knowledge or technical skills. This role gives emphasis on health promotion and health maintenance
• Counselor. The nurse helps the client to recognize and cope with stressful psychological or social problems, to develop improved personal relationships and promote personal growth. This role includes providing emotional, intellectual and psychologic support
• Client Advocate. The nurse promotes what is best for the client, ensures that the client's needs are met and protect client's rights
• Change Agent. The nurse initiates changes and assist the client make modifications in the lifestyle to promote health
• Leader. The nurse through the process of interpersonal influence helps the client make decisions in establishing and achieving goals to improve his well-being.
• Manager. The nurse plans, gives directions, develops staff, monitors operations, gives rewards fairly and represents both staff members and administration as needed. The nurse manages the nursing care of individuals, groups, families and communities. The nurse manager delegates nursing activities to ancillary workers and other nurses and supervises and evaluates their performance.
• Researcher. The nurse participates in scientific investigation and sues research findings in practice. The nurse helps develop knowledge about health and the promotion of health over the full life span; care of persons with health problems and diasbilities; and nursing actions to enhance people's ability to respond effectively to actual or potential health problems
• Case Manager. The nurse coordinates the activities of other members of the health care team, such as nutritionists and physical therapists, when managing a group of client's care
• Collaborator. The nurse works in a combined effort with all those involved in care delivery, for a mutually acceptable plan to be obtained that will achieve common goals. The nurse initiates nursing actions within the health team.

Nursing Board Resolution on Oathtaking

Ethics in Nursing

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• Ethics
1. Science that deals with principles of right and wrong, good and bad
2. It governs our relationship with others
3. Based on personal beliefs and values
• Principles
1. Respect for persons
2. Respect for autonomy
3. Nonmaleficence and benificence
4. Justice
5. Truthfulness
6. Confidentiality
7. Fidelity

• Nursing practice is governed by legal restrictions and professional standards
• What a nurse can do depends on the nurse practice act in the state in which the nurse is licensed
• Each state defines what constitutes professional misconduct
• The state board of nursing has the authority to impose a penalty for professional misconduct
• Penalties include probation, censure, reprimand, suspension or revocation of the license
• Standards of nursing practice apply to all nurses in all practice settings
• Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional nursing associations and accrediting groups
• To avoid negligence:

1. Know the standard of care
2. Deliver care that meets the standard and follows the facility's policies and procedures
3. Document care accurately and in a timely manner

• The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your facility. A relative or heir to the estate should never be the witness to the signing of an advance directive
• Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship
• Ethical dilemmas result from conflicts in values
• An effective leader modifies his/her style according to the situational requirements
• Final responsibility for any delegated task resides with the Registered Nurse
• The Registered Nurse must monitor delegated tasks and evaluate the outcomes

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