Ethical and Legal Aspects of Health Care and the Role of the Advanced Practice Nurse

Transcription

1 1 Ethical and Legal Aspects of Health Care and the Role of the Advanced Practice Nurse Introduction Impending health care reform in the United States is setting the stage for rapid and significant changes in health care delivery. Financial constraints and rapidly increasing consumer demand are critical factors impacting the role of the advance practice nurse (APN). If not already the case, it can be argued that the vast majority of APNs will soon be required to function at the highest level of professional autonomy, using their knowledge and skills to the fullest extent. As APNs step up to these expectations, it is once again important to explore, review and understand key ethical, legal and regulatory issues. As a novice APN, taking ownership of this knowledge is of even greater importance as entry into this prominent role significantly increases the risk of being exposed to legal and regulatory disputes. Self-reflection on the meaning of ethical and legal aspects A thorough understanding of the ethical principles in healthcare delineates to the APN (both novice and expert) what acceptable professional behavior and thinking looks like and how our peers, society and our critics expect us to behave. The major ethical principles I frequently reflect on, a short definition of each and examples from my practice are reflected in Appendix A, Table 1. These ethical principles form the basis of the American Nurses Association Code of Conduct, underscore the APN scope of practice as set forth by regulatory agencies such as boards of nursing, and become the standard by which we are judged. It guides us in ethical decision making and ethical actions and serves as a social contract with society. In consideration of legal and regulatory issues, I regard the ethical principles underscoring my judgment as the first line of protection in the realm of legal risk management. The second line of defense is a thorough understanding of current regulatory boundaries and legal concepts. Despite differences in APN scopes of practice across the nation, state boards of nursing, each through their own scope of practice documents, provide express regulatory guidance and authority to APNs to render certain types of patient care. As progress is made in the negotiation of a nationwide consensus model for APN practice, it

2 2 is imperative that I regularly review national and state-specific scope of practice guidelines and update my knowledge and understanding of my state- and role-specific scope of practice. I regard the third line of protection/defense as those aspects wherein I may exercise a higher degree of participation or control. These would include: (a) life-long learning to facilitate evidence based practice and clinical skill development, (b) appropriate collaborative and supervisory practice agreements, (c) accurate, complete documentation of all aspects of care, (d) compliance with standards of protection of health information, (e) appropriate and honest reimbursement practices, (f) vigilant use of prescriptive authority, and (g) appropriate professional liability insurance. Further discussion of these aspects can be found in subsequent paragraphs. Course outcomes and program outcomes The course outcomes (CO) for NU608 Health Care Practicum III: Specialty Focus and MSN program outcomes (PO) all relate to some extent to the anticipated ethical and legal issues facing APNs. The ability to integrate knowledge (CO#1 & PO#2) and apply critical thinking skills in diagnosing and decision-making (CO#2 & PO#4) enables the APN to recognize situations where the needs of a patient may exceed the APN s scope of practice or clinical competence. In designing therapeutic interventions (CO#5) the judicious APN distinguish between instances where he/she can safely render care to a patient and situations where appropriate treatment, such as invasive surgery, falls outside the scope and clinical competency of the APN. The risk of litigation is also managed when the APN exhibit the ability and prudence to evaluate diagnostic test results with interdisciplinary team members (CO#6) and is able to effectively communicate at an advanced level with collaborative partners and team members (CO#3 & PO#3). Mindfully incorporating ethical and legal principles into patient care (CO#7) and utilizing research findings in doing so (CO#8) is a vital step in developing culturally appropriate, individualized and holistic care and patient/family education (CO#4 & PO#5). Effective communication across the rolespan of advance practice nursing (PO#7) is not only a vital role function as it relates to patient care but also ensures the APN is able to provide organizational leadership while demonstrating knowledge of

3 3 health policy and health care systems (PO#1). Setting high personal standards for ethical behavior and a jurisprudent attitude (PO#6) enables the APN, both as clinician and as stakeholder in the business of healthcare, to lead by example. How legal aspects of advance practice nursing are demonstrated in my specialty practicum As a student APN it has become a habit to learn something new or review existing knowledge on a daily base. Mentored by professionals who value life-long learning further fortifies my conviction that continuous knowledge and skill development are not just good habits of a diligent clinician but also a major strategy to mitigate legal risks. My preceptors and I consistently review evidence based practice guidelines, clinical alerts and current standards of care. These knowledge checks as well as participating in collaborative discussions with interdisciplinary team members provide a gauge to compare our actions against that of our peers aiding in our ability to exercise reasonable care and skill in the provision of care. It also mitigates the risk of negligence or failing to provide, in similar circumstances, care of the same standard as a reasonable body of our peers. Additionally, my preceptor ensures that I am appropriately supervised, guided and mentored during my practicum experience and we maintain open communication to identify areas where knowledge and/or skill deficits still exist, and negotiate appropriate action and additional learning experiences. An awareness of legal aspects and implications is also evident in our discussion of factors such as: (a) informed consent (or informed refusal or withdrawal of consent), (b) factors which would render a patient incompetent to make health care decisions, (c) the differences between impaired judgment and incompetence, (d) legal requirements for advance directives, medical power of attorney/proxy documents, and (e) issues surrounding minor consent and privacy. Amid many challenges associated with a hard-copy medical record system, complete and accurate documentation is a major priority in my practicum setting. Despite it being very time consuming, significant efforts are made to accurately document on-site, telephone and mail encounters. Documentation includes: (a) discussions regarding diagnostic and treatment options, (b) discussions regarding diagnostic test results and copies of results, (c) recommendations for new, maintained or

4 4 discontinued treatment, (d) informed consent or informed refusal, (e) referrals for specialty consultation, (f) current patient problem and medication lists, (g) missed appointments, (h) prescription refills, (i) educational materials provided, (j) advance directives or health care proxy agreements, and (k) special considerations to facilitate provision of culturally competent care. Where treatment deviated from clinical guidelines or recommendations, documentation also include aspects of the decision-making process and contributing factors to justify the deviation. Accurate documentation of medications and prescriptions receives ongoing attention to increase accuracy and consistency with regards to: (a) including the purpose of the medication as part of the prescription, (b) avoiding error-prone abbreviations, (c) distinguishing between medications which have similar-sounding names or look alike, and (d) providing patients with user-friendly information regarding purpose, dosing, frequency, indications, potential side-effects/adverse effects and anticipatory guidance. Considering protection of health information, patient health information is kept in compliance with established standards and periodic audits of patient records occur. In accordance with state and federal law, patient health information records are retained and kept in a secure, access-controlled area of the clinic. All patients receive written notice of their privacy rights and enter into a privacy agreement with the clinic once they establish care. If consent for disclosure of health information to parties outside the organization is obtained, it usually is limited in terms of time, purpose and person. As a student and guest in the clinic, I am attentive of my handling of patient records being vigilant not to overstep any privacy agreements or compromise the security of health information and personal identifying information. I also reviewed the clinic policies and protocols regarding protection of patient information on my first day of clinical practicum and exercise vigilance in maintaining course related documentation without compromising patient privacy. My preceptor and I incorporate discussions regarding sound coding, billing and reimbursement practices into my clinical experience to aide in a better understanding of the business-side of health care. Prominent in rural health care settings, aspects of incident to billing are a main focus. We often discuss

5 5 the requirements for this type of billing where Medicare allows full reimbursement of services provided by an APN if such services occur within a collaborative partnership with a physician and meets certain criteria. As part of a formative discussion with my APN-preceptor, I gleaned a much better understanding of the intricacies of professional liability insurance and the differences between different types of policies such as occurrence-based and claims-based policies. Anticipating the requirement to obtain Federal Drug Enforcement Agency (FDA) authorization to prescribe controlled substances, I also frequently engage in discussions about this topic with my preceptors. Navigating such a complex issue seems intimidating but consistently reviewing regulations, policies and protocols on the subject is strengthening my understanding of the pitfalls of this significant responsibility. How I will incorporate this into my future practice Possessing and gaining determination, clinical skill, competence, sound decision making capabilities, personal and professional accountability and increased autonomy cannot be separated from those actions needed to empower myself as a safe APN. In my future practice, I plan to incorporate ethical, legal and regulatory aspects and manage professional liability by: a. Practicing within the boundaries of my state Nurse Practice Act and regularly updating my knowledge and understanding of these regulatory aspects. b. Practicing within the boundaries of organizational policies and procedures and frequently updating my knowledge of these, verifying that there are no conflicts with the scope delineated by the regulatory authority. c. Practicing within the national standards of care and consistently updating my knowledge and understanding of evidence based practice guidelines and recommended standards of care. Utilizing this knowledge in clinical decision making and seeking collaborative guidance for areas where guidelines may be ambiguous or where deviation from standards may be justified.

6 6 d. Recognizing when the care needs of a patient exceeds my scope of practice, clinical expertise or level of comfort and making timely referrals to establish appropriate care for the patient. e. Endeavoring to maintain documentation of patient care assessments, observations, diagnostics, communication and actions. To do so in a timely, complete, accurate, legible, objective and appropriate manner and to secure health information records according to laws and protocols directing protection of health information and personally identifying information. f. Endeavoring to continuously carry and meet the criteria for appropriate professional licensure and certification, FDA regulatory authorization and professional liability insurance. g. Being attentive to my abilities and level of experience and diligently negotiate employment contracts with attention to appropriate orientation, mentoring, supervision, professional support and collaboration. h. Engaging in continued learning, skill refining and professional development activities such as workshops, conferences, educational programs and peer interaction. i. Expanding and updating my knowledge regarding reimbursement practices, health insurance reform and/or healthcare policy revisions by maintaining an active interest in these subject areas. j. Developing a strong professional identity and gaining access to APN practice related issues through participation in professional organizations such as the American Nurses Association, the American College of Nurse Practitioners and/or the American Academy of Nurse Practitioners. k. Reflecting regularly on the ethical principles underscoring the nature of my advance practice.

7 7 References Aleshire, M. E., Wheeler, K., & Prevost, S. S. (2012). The future of nurse practitioner practice: A world of opportunity. Nursing Clinics of North America, 47, doi: /j.cnur Fisher, R. (2009, December). Relationships in nurse prescribing: revealing the process. British Journal of Community Nursing, 14(12), Retrieved from web.ebscohost.com.topekalibraries.info/ehost/pdfviewer/pdfviewer?vid=3&hid=8&sid=ce38b1ec c-a6c2-f6a2e48be3ab%40sessionmgr11 Griffith, R. (2008). Nurse prescribers, care pathways and the law. Nurse Prescribing, 6(10), National Council of State Boards of Nursing. (2009). Changes in healthcare professions scope of practice: Legislative considerations. Chicago, IL: National Council of State Boards of Nursing. Washburn University School of Nursing (WUSON). (2012, Fall). Course syllabus: NU 608 Health Care Practicum III. Retrieved September 12, 2012 from Washburn University Angel website: Washburn University School of Nursing (WUSON). (2011). MSN Student Handbook Retrieved September 12, 2012 from Washburn University Angel website: Weiland, S. A. (2008). Reflections on independence in nurse practitioner practice. Journal of the American Academy of Nurse Practitioners, 20, doi: /j x

8 8 Appendix A Table 1 Definitions and practice examples illustrative of the major ethical principles Ethical principle/ Related concept Beneficence Nonmaleficence Autonomy Utilitarianism Justice Definition The obligation to help people in need Do no harm / minimize harm. (Often the result of beneficence.) The right of a competent person to exercise selfdetermination Doing the best for greatest number of people Treating all persons the same regardless of individual characteristics / No discrimination Example from practice Demonstrated daily in clinical encounters where care actions are motivated by a sincere desire to help persons in need and in helping, opting for the course of action which renders the wellbeing of the patient, and benefit to the patient as highest priority. When the patient s well-being is the top priority, nonmaleficence is demonstrated when I exercise caution when performing a medical or surgical procedure (such as the destruction of a lesion or a joint injection) or when weighing the risk of a treatment, such as corticosteroid therapy, against the benefits. Demonstrated in my acceptance of a patient s decision to decline recommended diagnostics and/or treatment in spite of significant evidence that timely diagnosis and effective treatment modalities are available and may reduce morbidity and delay mortality. Example: 72 year old female with significant family history of colon cancer, who makes the informed decision not to pursue diagnostic studies and/or treatment interventions. Demonstrated in the prudent allocation of limited resources. Example from practice: Encouraging sexually active teen and young adult patients to receive appropriate screening and treatment for STIs following an increased incidence of chlamydia infection in the community. Despite some patients initial reluctance to be tested, explaining the benefit to many others (limiting the spread of STIs) motivated several patients to be tested. Screening was limited to sexually active patients only to ensure adequate number of screening kits available for those with recognized risk of infection. Demonstrated in organizational policy and implementation of such policies to ensure that all patients are treated in the same way regardless of race, color, religion, age, national origin, ancestry, disability, sex, marital or parental status, or sexual orientation.

9 9 Table 1 (continued) Definitions and practice examples illustrative of the major ethical principles (continued) Ethical principle/ Related concept Toleration Human dignity Totality Veracity (Related concept: Full disclosure) Definition Recognizing, respecting and accepting differences between patient and provider. Recognizing the inherent worth of each human being Considering client as a holistic being values the integrity of the whole person Being truthful & avoiding deceit, misconceptions or misrepresentation Example from practice Closely linked to the principle of justice, toleration is evident when, in addition to nondiscriminatory practices the provider also endeavors to individualize treatment based on the unique client characteristics (cultural background, language, religion etc.). Example: providing a separate waiting area and female-provider-only care to a conservative Islamic female patient. Closely related to the principles of justice and toleration, I value and guard human dignity by treating each patient with kindness, respect and empathy. This is especially important for patients who may be regarded of less value to society such as the advance geriatric patient, the dying, disabled, or incompetent patient. In all facets of care, the integrity of the whole person (physical, mental, spiritual and social) is valued and guarded. Example from practice: the discontinuation of a pharmacological treatment (Simvastatin) where the risks of continuing treatment (the occurrence of rhabdomyolysis) far outweighs the benefits of the treatment (lowering cholesterol levels). Demonstrated when the providers (both preceptor and student) provide patients with all information needed to make informed decisions. Example: explain to a patient with a pulmonary embolism, the risks associated with anti-coagulant treatment as well as the range of possible consequences if treatment is delayed or deferred. All questions were answered truthfully, not withholding information regarding possible serious consequences of both treatment and failure to treat.

10 10 Appendix B Course Outcomes for NU 608 Health Care Practicum III: Specialty Focus At the completion of the nursing program, the learner will be able to: 1. Integrate knowledge from previous courses to care for diverse patients in primary care settings. 2. Apply critical thinking skills in the development of differential diagnoses related to select health problems 3. Exhibit advanced communication skills in interdisciplinary settings. 4. Develop culturally appropriate, individualized patient/family education programs. 5. Design therapeutic interventions to maximize health and wellness of diverse populations. 6. Evaluate diagnostic test results in collaboration with interdisciplinary teams. 7. Incorporate principles of ethical and legal practice in primary care settings 8. Utilize research in providing culturally competent care.

11 11 Appendix C End of Program Outcomes for the Master of Science Degree in Nursing At the completion of the nursing program, the learner will be able to: 1. Provide organizational leadership demonstrating knowledge of health policy and health care systems. 2. Integrate knowledge and theory into evidence-based practice and research. 3. Collaborate with interdisciplinary groups within the role and scope of advanced practice nursing. 4. Demonstrate sound critical thinking and clinical decision-making. 5. Provide holistic care that is culturally proficient with diverse groups and communities. 6. Incorporate ethical and legal principles in health care policies. 7. Integrate effective communication in advanced nursing roles.