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Nursing ethics,crnp.04.12


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CRNP Nursing Ethics and Documentation

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Nursing ethics,crnp.04.12

  1. 1. ETHICS, DOCUMENTATION and PUBLIC HEALTH NURSING NURSI Department of Public Health April 13, 2012 By John R. Wible, General Counsel (Retired) Alabama Department of Public Health
  2. 2. An Ethical Person• Are you an ethical person?• From where or whom did you learn your ethical principles? – Hint: “Yo Mama”• “All I Ever Needed to Know, I learned in Kindergarten”• Role of Supervisor as example John R. Wible, 2012 2
  3. 3. The Pareto Principle• The “80-20 Rule” revisited • 10% basically ethical • 10% basically unethical or “aethical” • 80% wandering in the middle• The ethical job of the manager • Differentiate the animals • Lead the sheep in the right way John R. Wible, 2012 3
  4. 4. John’s Five Action Principles• To tell the truth, the whole truth and nothing but the truth• “We’ll Sing in the Sunshine”• Casper the Friendly Ghost• It’s not about me• The “Nike Principle.” John R. Wible, 2012 4
  5. 5. Sources of PersonalEthical Principles• The Ancient Greeks• Religious teachings• Cultural teachings -American Historical Documents – Declaration of Independence – United States Constitution John R. Wible, 2012 5
  6. 6. Socrates, Plato, Aristotle; Greeks L:Plato and Aristotle by Raphael R:Raphael’s Socrates • Socrates – “know thyself” • Plato – human well-being, the highest aim of moral thought and conduct • Aristotle – apply what we know in social settings John R. Wible, 2012 6
  7. 7. Religious Ethical Principles John R. Wible, 2012 7
  8. 8. American Historical Documents • Declaration of Independence • United States Constitution 1776 John R. Wible, 2012 8
  9. 9. Declaration of Independence• Set forth the “self evident truths” such as “equality”• Established an ethical basis for independence• What Locke applied to individuals, Jefferson applied to a people – John Adams• Did not address African slavery John R. Wible, 2012 9
  10. 10. Constitutional Principles• “We, the People” – social contract based in personal autonomy• “Establish justice” – – Equity – Equality – Fair process• “Insure Domestic Tranquility” – peace• “Promote the General Welfare” John R. Wible, 2012 10
  11. 11. Professional Ethics• Hippocratic Oath and Medical Ethics• Augustine’s “Just War”• Nursing Ethics• The Public Health Code of Ethics• Public Officer/Employee Ethics Laws John R. Wible, 2012 11
  12. 12. Utilitarianism vs. Egalitarianism • Jeremy Bentham’s theory of utilitarianism what is right or good based on whether the consequences will be good • Immanuel Kant’s egalitarianism theory focuses on non- consequentially based notions of good - deciding what is right or good is based on meeting duties and obligations • These contradistinguished ideas will clash over and over ADPH, 2012 12
  13. 13. Oath of Hippocrates – Medical Ethics• “Primum non nocere” – first do no harm• Always look to the good of the patient• Place a high value on human life• Perform only within one’s training and skill• Refrain from improper relations with patient• Maintain patient’s secrets inviolate• Do not violate community laws or morals John R. Wible, 2012 13
  14. 14. Nursing’s Primary Ethical Principles • Respect for autonomy • Non-malfeasance • Beneficence • Justice John R. Wible, 2012 14
  15. 15. Respect for Persons/Autonomy• People are treated as autonomous agents• Protection for those of diminished capacity• Informed consent defined• Period reviews of status of subjects required John R. Wible, 2012 15
  16. 16. Beneficence• Look out for the “broader good” “Beneficence” – Ball State University of the subject• Do no harm• Does it actually do some good?• Balance the risks against the benefits John R. Wible, 2012 16
  17. 17. Justice• Applies the allocation of risk or burden to benefit to the subject and to the proposed benefited population – Are these welfare patients, – from a particular socio-economic or ethnic background, – confined populations such as prisoners• Formulations for distributing benefits and burdens: – to each person an equal share, – to each person according to his or her need, – to each person according to societal contributions past and future – to each person according to (perceived) merit John R. Wible, 2012 17
  18. 18. Secondary Principles • Veracity – duty to tell the truth, the whole truth and nothing but the truth* • Confidentiality – duty to respect privileged information • Fidelity – duty to keep promises * Ask Former Coach Bobby Patrino John R. Wible, 2012 18
  19. 19. ANA Provision 2.3 Additions• Identify and Avoid conflicts of interest• Duty to collaborate not just get along• Practice within professional boundaries• Don’t further questionable practice – Report it and get guidance• Don’t practice in impaired condition John R. Wible, 2012 19
  20. 20. Provision 4 Delegation• Make proper delegations, taking responsibility for such delegations• Only delegate to a person capable of carrying out the task whether the pt, family member or subordinate• Educate subordinates who are incapable• Improper delegation = abandonment John R. Wible, 2012 20
  21. 21. ANA Provision 5 Integrity • Practice with integrity • If you are a conscientious objector, advise supervisor of such • Conscientious objection does not insulate from legal or administrative penalties • If you can’t stand the heat, get out of the kitchen John R. Wible, 2012 21
  22. 22. Nondiscrimination & Risk• Provide care in a “non-discriminatory manner• There are limits to the amount of personal harm required to risk• Cannot abandon a patient• Personal risk may depend on the individual condition of the nurse• A “sacred duty” – American Nursing Association – December 1994 John R. Wible, 2012 22
  23. 23. Hierarchy of Obligation Follow your principles Reconcile these or . . . John R. Wible, 2012 23
  24. 24. Professional Implications - Case• J.L. (17 WF) presents abdominal pain• Mom signs admit forms & Pt. BOR, RN x2• Temp – 100.8°; U/S ≠ app’s• RN assumes Mom to remain in exam R• JL denies ♂ , day 2 menses• 2 hr delay – lost urine sample; Pelvic - difficult• PG test (-), both informed John R. Wible, 2012 24
  25. 25. A Public Health Study• Problems most often required relational response not option choice• Goal – optimize the pt. good/ maint. supportive relationship w/other staff• Five consistent “themes” – Rel. w/staff – systems issues – Character of relationships; respect/pt – Putting self at risk John R. Wible, 2012 25
  26. 26. Public Health Code of Ethics Twelve Principles1. Addresses causes of disease to prevent.2. Respects the rights of individuals in the community.3. Utilizes community input in program development.4. Advocates “empowerment” of the disenfranchised.5. Seeks the information needed before acting.6. Provides the community with information to decide.7. Acts in a timely manner on the information.8. A variety of approaches anticipate and respect diversity.9. Enhance the physical & social environment.10. Confidentiality - Exceptions must be justified.11. Professional competence.12. Work collaboratively to build the publics trust. John R. Wible, 2012 26
  27. 27. Public Health Values• Reaffirms the Declaration of Human Rights• Humans are inherently social and interdependent, thus the principle of “community”• Community is perpetually balanced as against the rights of the individual• Public trust and transparency John R. Wible, 2012 27
  28. 28. Public Health Values - 2• People and their environment are interdependent• Upheld by the science of prevention• Appropriate gathering, use and dispersion of knowledge• The Code requires action John R. Wible, 2012 28
  29. 29. Public Officer and Employee Ethics lawsNo public official or public employee shall use or cause to be used his or her official position or office to obtain personal gain for himself or herself, or family member of the public employee or family member of the public official, or any business with which the person is associated unless the use and gain are otherwise specifically authorized by law. Personal gain is achieved when the public official, public employee, or a family member thereof receives, obtains, exerts control over, or otherwise converts to personal use the object constituting such personal gain John R. Wible, 2012 29
  30. 30. Nature and Scope of Public Ethics Laws• Very narrowly constructed and construed• Contrasted with the broad sweep of professional codes John R. Wible, 2012 30
  31. 31. Documentation• Baseline patient information• Accessible details in the event litigation occurs• Record of professional accountability• Evaluation of performance and quality of care• Show that standards of care have been met• Provides continuity of care• Substantiates proof of services (so you can bill) John R. Wible, 2012 31
  32. 32. Good Documentation• Use factual, consistent, accurate, objective and unambiguous patient information• Use your senses to record what you did• Use quotation marks where necessary• Ensure there is a reasoned rationale (evidence) for any decision recorded• Ensure notes are accurately dated, timed, and signed John R. Wible, 2012 32
  33. 33. More Good Documentation• Write up notes as soon as possible after an event certainly w/in 24 hours• Document any objections to care• Do not include jargon & meaningless phrases John R. Wible, 2012 33
  34. 34. The “Golden Rule of Documentation” If it ain’t wrote down it didn’t happen!The way it is wrote down is the way it happened regardless of the way it happened! John R. Wible, 2012 34
  35. 35. Confidentiality andAccess to Records John R. Wible, 2012 35
  36. 36. Imperatives for Protecting PHI • Responsible sharing of some PHI is necessary • All we have to sell is the patient’s trust in us • Individual privacy protections must balance with legitimate community uses of PHI John R. Wible, 2012 36
  37. 37. Confidentiality-Access to Records • All patient information is strictly confidential • Bad scenarios usually equal bad liability – Mom’s friend at the window – Nurse’s BFF’s boy friend John R. Wible, 2012 37
  38. 38. Conditions for Release of Information• Prior written consent –Patient –Parent/guardian• Subpoena in accordance with departmental/institutional policy• Otherwise provided by law John R. Wible, 2012 38
  39. 39. Written Authorization Not Required• Transfer information to physicians, health professionals with contract or other provider arrangements to provide care• Some practitioners require consents to transfer out of abundance of caution John R. Wible, 2012 39
  40. 40. A Valid Authorization?escription of the info releasedame or description of info receiverame of patientescription if the use of the info John R. Wible, 2012 40xpiration date or continuous
  41. 41. Confidentiality - Access to Minor’s Medical Records• If a minor is qualified to consent and signs the “consent for treatment”, only the minor can sign to release the information regarding those services• If the parent/guardian signs the consent for treatment, the parent/guardian or the minor may consent for the release John R. Wible, 2012 41
  42. 42. Access to Minor’s Medical Records - Parents’ Rights• All information pertaining to a child must be equally available to both parents –However, if the child gave consent for services, neither parent may have access to the records without that child’s consent –Code of Ala, § 30-3-154 John R. Wible, 2012 42
  43. 43. State Law Penalties Unlawful Release Of Info• Criminal § 13A-11-35 – “Divulging illegally obtained information”• Civil actions (lawsuits v. the RN & Dept.) – Suits for invasion of privacy – Outrage - willful and wanton misconduct – Breach of implied contract• Administrative – Loss of license or of job John R. Wible, 2012 43
  44. 44. The Privacy Rule: What is Covered?• Protected Health Information (PHI) – Individually-identifiable health information used or disclosed by a covered entity in any form, whether electronically, on paper, or orally – 45 C.F.R. §160.103 John R. Wible, 2012 44
  45. 45. Uses Without Written Consent• Treatment T• Payment P• Operations O• Where required by law John R. Wible, 2012 45
  46. 46. Minimum Necessary Rule:“When using or disclosing PHI, a covered entity must make reasonable efforts to limit such information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request” John R. Wible, 2012 46
  47. 47. Who Needs to know?• Outside the “need to know” never reveal a patient’s name, what he said, unusual behaviors or conditions or lifestyle• Don’t even discuss patients with co- workers outside the need to know• Never discuss patients outside the workplace unless authorized John R. Wible, 2012 47
  48. 48. HIPPA - Disclosures Permitted“Minimum” info may be disclosed to: – Public officials – Public health – Law enforcement (LE) – National security & intelligence agencies – Judicial authorities – Researchers – DHR or LE for abuse reporting John R. Wible, 2012 48
  49. 49. HIPPA Breaches• When there is a breach of protected info, the CE has a duty – To report to or notify clients – To report to HHS and the media if >500 – To mitigate the damage – To examine employees, policies, equipment and facilities to prevent it John R. Wible, 2012 49
  50. 50. HIPAA Breaches - Penalties• Breach may subject employees and the Department: – To criminal penalties up to $250,000 – To HHS civil penalties or HHE or private lawsuits – To adverse employment action – I.e., . . . . . . . . . . . . . . . . . . . . John R. Wible, 2012 50
  51. 51. Individual Methods to Avoid Liability• Avoid inappropriate behaviors• Participate in Con-Ed programs• Know and follow policies , protocols, procedures, laws and regulations• Strictly adhere to training protocols• Strictly follow instructions of medical direction and superiors• Document, document, document John R. Wible, 2012 51
  52. 52. For A Copy of Presentation and a Paper►See “ETHICS, DOCUMENTATION and PUBLIC HEALTH NURSING” NURSI►See several presentations & documents also:►Blog:►Also on Facebook 52 John R. Wible, 2012