Ethical Legal Dilemma in Advanced Practice Nursing

Ethical Legal Dilemma in Advanced Practice Nursing

Ethical Decision Making Model

AACN’s (2014) four “A’s”, Ask, Affirm, Assess, and Act model assists nurses to solve moral distress and address ethical concerns in practice. The nurse manager first asks if an ethical problem is presenting itself. It is affirmed that the situation at hand could create harm to patients. The nurse manager assesses the staffing and notes that ratios are now followed but skill level is compromised needing further action.

Solution

Coherence in legal reasoning is the rationale behind the process to determine if a legal dilemma is occurring with California law AB 394 specifically outlining nurse to patient ratios in critical care. (National Nurse, 2013). The nurse manager is aware of the clear guidelines the law states justifying action to adhere to ratios.

Interpretation in legal reasoning is an important nursing function for the nurse manager, as this is the understanding of the laws in place for nursing practice and solutions to ensure compliance with laws can be developed (Grant & Ballard, 2011). Securing appropriate staff adheres to California law AB 394 supporting the nurse manager's decision to keep a nurse on overtime.

Logic in legal reasoning allows the advance practice nurse to examine laws to determine compliance when presented with a legal dilemma. The California ratio law is specific to critical care settings, yet does not distinguish as to training specific to the specialty. This supports the nurse manager's decision to keep nurses of all levels on shift.

Ethical Violations

Legal Reasoning Constructs

The Nurse Manager comes out to the unit to work directly with staff in order to resolve the staffing situation and to assist in solving this safety dilemma. Demonstrating fidelity in practice, the Nurse Manager is willing to come into the unit and work at the bedside along with the rest of the nurses in order to serve as a resource and provide breaks. This demonstrates ethical practice of beneficence as patient safety is taken into consideration by remaining actively available and serving as a resource.

A clear understanding by the advanced practice nurse of the law is essential to resolve legal conflicts in practice. Legal reasoning constructs guide the nurse manger supporting decision making.

The nurse manager first checks in with the novice nurse and immediately goes to see the patient with the late medication to administer it. The missed medication for vasospasms, after aneurysm clipping, is given late and the patient is currently not experiencing any symptoms. The patient's family noted that half an hour ago the patient was slurring her words. The nurse manager updates the novice nurse and the physician is notified. The patient is stable and further harm is avoided.

Legal analysis assists the nurse manager to investigate the problem presented to understand the laws that must be followed. Laws are set in place to create a safe healthcare environment for patients which include staffing ratios. The minimum legal requirement that must be maintained by the nurse manager is upheld supporting the staffing decisions.

Case law sets a precedence for adhering to the law. In the case of County of Kern v. California Department of Health (2009), the Kern County Medical Center was found guilty of exceeding nurse to patient ratios and fined in the method of decreased Medi-Cal reimbursement. Despite the medical center indicating that various levels of care were provided during the time staffing was in question it was determined that there was inadequate staffing. The nurse manager's decisions are supported by established case law.

The elements and logic of ethical reasoning identify the method of deriving a solution to ethical dilemmas while explaining how the decision was created. Just as there is a nursing process for developing a plan of care, there are various methods for use to create solutions to ethical dilemmas such as the model described by AACN.

Advantages and disadvantages to ethical reasoning are identified, as these affect the current case study. Advantages to ethical reasoning include guides and models that assist to determine if an ethical dilemma is present, providing guidelines to troubleshoot the issue. Disadvantages to ethical reasoning are linked to the emphasis on creating a solution. Team members may become so involved in attempting to resolve an ethical dilemma that patient care is compromised and there may be falsely identified ethical dilemmas that are not ethical concerns.

Ethical conduct in nursing should remain independent of pseudo-ethical beliefs. One’s own personal religious or cultural views may guide morality, but there are distinct ethical principles the nursing profession follows to ensure actions are beneficial to people of all beliefs.

Ethical duties and patient safety are interlinked in practice, where ensuring that patients do not experience any undo harm as being a priority that is put at risk if proper staffing is not maintained (Kangasniemi, Vaismoradi, Jasper, & Turunen, 2013). Since the nurse administrator is aware of an unsafe situation, action must be taken to immediately remedy the problem to avoid harm to patients, maintaining the ethical value of non-maleficence.

Ethical Reasoning Constructs

Legal Violations

The function of ethical reasoning, as established by professional organizations, enables the advance practice nurse to perform duties ethically. Ethical codes of conduct are established by the profession to maintain the highest standard of care which is not legally binding (Marquis & Huston, 2012). This guides professional nurses to the appropriate way to act, while maintaining accountability.

Failure by the advanced practice nurse to secure enough staff to provide patient care will break the nurse to patient ratio law. In the State of California, AB 394 is the nurse to patient staffing law that must be followed in practice (National Nurse, 2013).

Civil and Criminal Violations

Not adhering to this law can be classified as both a civil violation and criminal act. The patient ratio of one nurse to two patients is the minimum standard of care for critical care specialties. A civil law is broken when the set standard of care is not followed (Grant & Ballard, 2011). A criminal act is a crime against public wellbeing where a governmental body files charges, with this situation being one in which the State of California is the enforcing entity (Grant & Ballard, 2011).

The nurse manager has just been told by the critical care director that budget has not been met due to increased overtime and staffing needs to be kept tight.

Advance practice nurses in leadership roles must be prepared to handle the complex ethical and legal dilemmas that arise in nursing practice.

Case Study

Solution

Aware that a legal violation will occur without action the nurse manager makes a decision to resolve this dilemma. The nurse manager joins the bedside nurses to secure staff. The nurse manager negotiates with a nurse to stay over ensuring that ratios are followed.

A nurse manager is made aware of a potential legal and ethical dilemma in a critical care unit.

Along with regulatory laws, there are ethical principles that guide nursing practice.

Veronica Stemler

Kaplan University

An ill call has left the unit understaffed. Along with not meeting mandated patient ratios the charge nurse has a patient assignment leaving the unit without a resource nurse.

A novice nurse is on duty and the resource nurse is busy with a full patient assignment. One patient the novice nurse is caring for is experiencing subtle changes in mentation after a missed morning medication. The change is unrealized by the novice nurse as she is busy caring for an unstable patient.

References:

American Association of Critical Care Nurses [AACN]. (2014). The 4A’s to rise above moral distress [PDF document]. Retrieved from http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_Distress.pdf

County of Kern v. California Department of Health Services, B211594 (Cal. Ct. App. Dec. 17, 2009).

Grant, P. D., & Ballard, D. C. (2011). Law for nurse leaders: A comprehensive reference. New York, NY: Springer Publishing Company.

Kangasniemi, M., Vaismoradi, M., Jasper, M., & Turunen, H. (2013). Ethical issues in patient safety: Implications for nursing management. Nursing Ethics, 20(8), 904-916. doi:10.1177/0969733013484488

Marquis, B. L., & Huston, C. J. (2012). Leadership roles and management functions in nursing: Theory and application (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

National Nurse (A Staff Report). (2013). Ratios, then and now. National Nurse, 109(8), 12.