Transcript Where Critical Care Registered Nurse Examination

The Register and Roll
• The 1999Act established a single register which records all
persons that have met the entry to practice requirements
for the registered nurse
• The roll records all persons who have met the entry practice
requirements for the enrolled nurse.
The Enrolled nurse
• Is a second level nurse who works under the supervision of
the registered nurse
National
Standards
Professional Nursing practice
Topic 01
National Standards
• The Australian Nursing and Midwifery Council (ANMC)
facilitates national standards for statutory nurse regulatory
authorities. These define the minimum core competencies
and expected standard of behavior/ conduct of all nurses
National Standards
• ANMC National Competency Standards for the Registered
Nurse and Enrolled Nurse
• ANMC Codes of Professional Conduct for Nurses in Australia
• ANMC Codes of Ethics for Nurses in Australia
Board Endorsed Standards
• There are a number of standards that have been developed
by national professional nursing/ midwifery organizations.
• These can be endorsed by the Nurses Board
Board Standards
• The Board has developed standards which apply to the
practice of nursing/midwifery and development of education
programs leading to registration and enrolment
• Board standards reflect the Nurses Act, Regulations and
contemporary regulatory practices
Board Standards
1. Standard for Medication Management
2. Standard for the Use of Restraint
3.
Standard for Therapeutic Relationships and Professional
Boundaries
4. Standards for Approval of Education Courses
5. Standards for approval as an Education Provider
Board Standards
6. Standards for Authorization for an Enrolled Nurse to
practice without the supervision of a registered nurse
7. Professional standards statement for Nurse Practitioner
Practice
Direct supervision
• Means that a registered nurse is present and works with the
enrolled nurse observing and directing his or her activities.
• The proximity of this supervision is such that immediate
intervention is possible if problems occur.
• The registered nurse is able to observe and monitor the execution
of the enrolled nurse’s activities and retains accountability.
Indirect Supervision
• Means the registered nurse is not present and supervision is
provided by other than direct observation, of an enrolled
nurse by a registered nurse.
• The absence of proximity of the registered nurse requires
processes being in place for the direction, guidance, support
and monitoring of the enrolled nurse activities. The
registered nurse retains accountability
Next week
Need to have a copies of
• Code of Ethics
• Code of Conduct
• ANMC Competencies
Activity - refer to them all three documents
Title and Content Layout with List
• Add your first bullet point here
• Add your second bullet point here
• Add your third bullet point here
Two Content Layout with Table
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Group 1
Group 2
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Class 1
82
95
• Third bullet point here
Class 2
76
88
Class 3
84
90
Professional
Nursing practice
Part I – Professional Nursing bodies
Part II- Scope of Practice
Part II – competency standards for EN and
RN
Professional
nursing bodies
Part I
South Australia
•
There are two professional bodies that guide nursing
practice in South Australia:
1.
The Nurses Board of South Australia (NBSA)
2.
The Australian Nursing Federation (ANF SA Branch)
NBSA
• Is the statutory body responsible for the administration of
the Nurses Act and maintenance of registration records
• In administering the Nurses Act it fulfils a particular
purpose by providing a set of standards that deal with
qualifications, duties and responsibilities within the State.
NBSA
• Some of the activities of The Board includes:
• Accountability – The Board requires practicing nurses to
maintain registration and enrolment annually with an
emphasis on the importance of ensuring competence
NBSA
• Education
• The Board determines the educational preparation of nurses
through approving courses that lead to registration and
enrolment
NBSA
• Conduct and Competence
• The Board ensures that people applying for registration and
enrolment have the competence, character, mental and
physical capacity expected of the profession.
Investigation and adjudication
• The Board investigates reports about nurses’ conduct,
competence or incapacity and hears matters determining
the outcomes to protect the public interest
The ANF
• Is the largest industrial body representing the interests of
nurses in Australia.
• The South Australian branch of this organisation is a State
Registered Union which represents nurses industrially and
professionally – just and the ANF does in other states
ANF
• The ANF has a dual role, which combines professional and
industrial responsibilities
• The ANF has had a major impact on the development of
nursing as a profession
ANF
• Has provided nurses with guidelines and contribute to the
development of the Australian Nursing Council (ANMC)
standards for the Registered and Enrolled Nurse
• It has also developed standards for self appraisal and the
relevant documentation for nursing care to be measured
Legal Context
• The creation of a set of standards within nursing has had a
major impact on the degree of accountability and
responsibility of both registered and enrolled nurses and has
helped define their roles
• With these guidelines in place, the legal system is then
provided with parameters within which nursing is performed
You as an Enrolled Nurse
• As an enrolled nurse, your role and function are defined by
the Nurses Board, ANF, your job description and the health
unit’s policies and procedures.
• How you practice these guidelines is influenced by your level
of responsibility and accountability.
Nurse’s contract with society
• Nursing exists to satisfy a fundamental need of humanity.
• Nurses are in a position to be aware of injustices in the
health care system and the political arena; therefore, they
have a duty to set an example and become involved.
Nurses’ professional role
• Nurses want the rights and privileges that accompany their
professional role, but they do not always want the
responsibilities that accompany these rights.
• It is not enough for nurses to simply care for patients; they
must advocate, educate and set and example to the public
Nurses’ professional role
• Many nurses do not want theses rights of responsibilities
preferring instead to focus on clinical tasks only.
• What is wrong with this?????
Nurses’ professional role
• This mentality is dangerous for nursing
• It will prevent nursing from progressing to a higher
professional level.
• If the main focus of the profession is task-orientated rather
than visionary, nursing will lose the battle for patient
orientated health care and greater respect for the nursing
profession
Leadership
• Having visionary nursing leaders in strategic positions in
health care facilities, professional organisations, and in local
and national offices, increases the influence of nurses and
therefore, their objective in the health care political arena
Ethical obligations
• On community and national levels nurses have an ethical
obligation to promote human rights awareness and influence
health care policies.
Benchmarks
• Rules of guidelines we work under, standards we meet.
• Nursing is regulated by many legislative acts and regulations
( as listed on NBSA website)
• All nurses must be particularly well aware of the
implications of The Nurses Act 1999 and the Consent to
Medical Treatment and Palliative Care Act 1995.
Nurses Board
• What is it’s function under the Nurses Act 1999
• To nurses
• To the public
Key Terms and what do they mean
to your practice
• Supervision
• Accountability
• Responsibility
What are national standards
• ANMC standards for EN’s
• ANMC Code of Professional Conduct
• ANMC Code of Ethics for Nurses
Board Endorsed Standards
• Reflect the Nurses Act, Regulations and contemporary
regulatory practices
Policies and Procedures
• Organizational policy and procedures are essential to guide
nursing practice within that particular organisation.
• They protect your practice within the workforce.
Policy and Procedure Statements:
How important are they?
• Take these seriously
• Often failure to follow protocol that gives the court cause to
review nursing practice
• Take care reading them – responsibility for failing to do so
will lie with the practitioner
Linda Saunders 7/12/04
Impact on Enrolled Nursing Practice
• Regulates the profession. Currently not all health
professionals are regulated.
• Only registered or enrolled nurses are entitled to be called
‘nurse’
• Nurses must function in accordance with Nurses Act and
legislation.
• Nurses must have an understanding of the legal implication
which effect their practice
Impact on Enrolled Nursing Practice
• Be aware of standards for restraint
• False imprisonment
• Tort of negligence
• Duty of Care
• Vicarious Liability
Impact on Enrolled Nursing Practice
• Conduct nursing in a way that can be ethically justified
according to code of ethics and professional code
• Respect the rights of individuals
• Accepts accountability and responsibility for own actions
within practice
• Assess their own practice
Impact on Enrolled Nursing Practice
• Maintain own professional development
• Practice in a safe manner
• Maintain professional confidentiality
• Ensures informed decision making
• Verifies consent for procedures
•
Aware what constitutes assault/ battery
• Understands advocacy
• Can identify the moral commitments of the profession.
Review of the Nurses Act
• The Nurses Act is currently under review
• Consultation is underway with all colleges of nursing and
general nurses and midwives
Key Issues for inclusion of amendment
• A separate midwifery register
• Regulation of students of nursing
• Definition of nurse practitioner
• Authority for prescribing of medication for nurse
practitioners and midwives
• Definitions of delegation, direct and indirect supervision
Key Issues for inclusion of amendment
• Evidence for continuing competence and scope of practice
• Review of the composition of the Board
• Review of authorization of enrolled nurses without
supervision
• Review of investigation and formal proceedings and processes
Why change?
• The Minister for Health has requested a review of
professional registration Acts.
• The Medical Practice Bill 2004 and Podiatry Practice Bill
2004 have both been tabled in the House of Assembly in
2004.
• It is likely the new Act will be changed to the Nurses and
Midwives Act
Hot topics
Taken from a talk by Linda Saunders
7/12/04
We now work in an environment
• That has alternative models of care from traditional hospital
focus
• What are they?
Linda Saunders 7/12/04
Alternative care models
• Impact of day surgery. Less time to access patients
• Primary health care.
Linda Saunders 7/12/04
Advances in Technology
• The Internet
• Research : legal implications
Linda Saunders 7/12/04
Fear of litigation
• Most health professionals fear being sued
• Personally and professionally devastating
• No more at risk than other members of the community
• All have a responsibility to avoid causing personal and
property damage
• Most litigation in health care settings attributed to
unsafe practice, negligent delegations or supervision of
staff.
Linda Saunders 7/12/04
Medical Litigation Explosion or Media
Sensationalism
• 555 million Medicare services a year
• 1.1 million hospital admissions
• At any one time 450 claims for all kinds of medical
negligence in Australian courts collected over 2-3 years
• Obstetric litigation expensive and protracted due to the
extent of time a claim can be made and the need to
investigate time from conception to birth
• 4% get to court
• 1% get to hearing
Linda Saunders 7/12/04
Case of Sophie Heatcote
•
Registered nurse on night duty at Wilcannia Hospital
•
Death in custody of Mark Anthony Quayle
•
Follow policy
•
Document clearly
•
Maintain a professional demenour
Activity – read the case
http://books.google.lk/books?id=ga0PYFkdAV4C&pg=PA4&dq=Case+of+Soph
ie+Heathcote&hl=en&sa=X&ei=3TxRUZ71KourrAevtYHACw&ved=0CCsQ
6AEwAA#v=onepage&q&f=false
Go through a day at work
• Go through the tasks you will perform in a single
working day
• Eg take handover
• Perform ADL’s
• Administer medications
• Document
• Speak to relatives
• Admit and discharge patients
• Patient education
What legal and ethical parameters impact on
your day to day practice?
Ethics
Topic 03
1.
2.
3.
4.
5.
Ethics
Theories
Principles
Resolving ethical dilemmas – models of
decision making
Discontinuing treatment
Not for resuscitations
Principle Based Ethics
1. Autonomy
2. Beneficence
3. Non-malificence
4. Justice
1. Principle of Autonomy
• Humans have the right to non – interference when making
decisions about themselves
• Free will , without any pressure ???
•
Health information asymmetry
• Forms the basis of ideas about privacy, confidentiality,
veracity, fidelity and consent
a. Confidentiality
• Not reveling information collected from the patient:
• Verbally
• Examination
• Records
• Complicated process
• Educate staff
• Security of Medical documents
b. Privacy
• Areas where patient does not want to reveal :
• History
• Examinations
• Complicated process:
• Social harm
• Social benefit
• Use your common sense
c.Veracity
• Revealing truthful information to the patient:
• As a professional
• Cultural /social /Medical
•
harm
• Benefit
d. Fidelity
• Practicing within the boundaries of Nursing
• Scope of practice
• Professional standards
e. Consent
• Intervention
• Wiliness to agree to undergo any intervention
• Implied
• Verbal
• Written
•
2. Principle of Beneficence
• “I will use treatment for the benefit of the sick, according to
my ability and judgment”
Hippocratic Oath
• Conduct is aimed at the good and well being of others
• Principle requires that practitioners provide both
appropriate treatment and an assurance that the treatment
will not produce more harm than good
3. Principle of Non-malificence
• “Above all do no harm” -Hippocratic Oath
• In health care the ethical issues of non-malificence and
beneficence are particularly apparent in decisions regarding
the institution of dangerous therapy or withdrawal of
therapy that is no longer thought to be beneficial.
4. Principle of Justice
• Justice as fairness
• Comparative Justice
• Distributive Justice
Identify the ethical problem
• Is it ethically reasonable to allow a person to stop eating and
drinking
• This situation was complicated by the fact that JD was
unable to communicate and may or may not be confused, or
in fact mentally competent
Mental competence
• We cannot proceed further with solving this ethical question
until we decide if JD is mentally competent.
• If after examination Mr. D is considered mentally
competent and able to communicate then continuing to drip
feed him is an unbearable assault on his person and the
decision to forgo treatment is straight forward
If JD is not competent
• ‘Can we ethically refrain from providing food and fluid to a
mentally incompetent individual who appears to have a poor
quality of life but will need to be restrained by force to feed
him’
What facts are available?
Will he be likely to suffer more from not feeding him or
restraining him and forcing food upon him?
Consider the four principles
• In JD’s case we cannot negotiate fully with him as he is not
mentally competent. So in order to respect his autonomy,
we must fallback on other ways of dealing with him, such as
involving family or close friends, ascertaining whether he has
left instructions about what do in this circumstance (advance
directives)
Consider the four principles
Although we wish to do our best to help him, we are still
unsure as to whether he will be best served by being allowed
to die or by being forced to live.
• Which option will entail the greater burdens?
• Which option will afford him and his family the most
justice?
There is no single answer
• A solution will only be obtained from collaboration within
the health team and with others who are close to the
patient
• Issues of justice, most commonly resource allocation may
become important
Identifying ethical conflicts
• There is a conflict between the principle of beneficence and
non-malificence.
• We wish to help this man, but we are unsure if our help will
actually harm him
Consider the Law
• We need to enquire of relatives whether JD had expressed
views about treatment he would have declined.
• In this case his wishes should be considered when deciding
treatment.
• None of the proposed courses of conduct would appear to be
deliberating intended to end JD’s life (which would be illegal)
Consider the Law
•
A court if asked to consider this issue would probably not
consider the withdrawal of treatment (artificial nutrition
and hydration) to be the primary cause of JD’s death.
• In this instance the approach that a legal enquiry would
follow would be the similar to that of ethics.
Making the Clinical Decision
• Gather all the relevant information and communicate
between health professionals, patients, families and between
members of the health team.
• The decision should be discussed with all concerned and
documented clearly in the notes, specifying who was involved
in making the decision and why the decision was made.
Making the clinical decision
• The decision should be reviewed at intervals as determined
by the clinical context.
• The decision may be reviewed after the patient has died, by
a clinical audit, the coroner, and the legal system
• It is important that individual practitioners evaluate their
own moral decisions
Clinical Ethics
• Since the 1970’s clinical ethics has developed.
• Clinical ethics committees have emerged within all
institutions
• They can assist with promoting and enhancing shared
decision making.
Ethics and Nursing
• Ethics when applied to nursing is the standard of behaviour
which nurses are expected to follow in the interest of the
public good
• A nursing code of ethics provides nurses with guidelines
which the standards of practice for the profession are
conceived, preserved and refined.
Code of Ethics for Nurses in Australia
• Has been developed for nursing in the Australian context and
is relevant to all nurses in all practice settings
• The code of ethics outlines the nursing profession’s intention
to accept the rights of individuals and to uphold these rights
in practice.
Code of Ethics for Nurses in Australia
Its purpose is to:
• Identify the fundamental moral commitments of the
profession
• Provide nurses with a basis for professional and self reflection
on ethical conduct
Purpose
• Act as a guide to ethical practice
• Indicate to the community the moral values which nurses
can be expected to hold.
• The code contains six broad value statements with
explanatory notes
Personal Moral Stance
• Nurses may adopt a personal moral stance that
would make participation in certain procedures
morally unacceptable to them.
• Nurses have a right to refuse to participate in
procedures which they judge on strongly held
moral beliefs to be unacceptable, however they must
ensure the quality of care and patient safety are not
compromised.
A framework for nursing ( 02)
• The Code of Ethics is supported by the Code of Professional
Conduct for Nurses in Australia. The Code of Ethics focuses
on the ethics and ideals of the profession.
Code of Ethics
Code of Ethics
Value statement 1
• Nurses respect individual needs, values, culture and
vulnerability in the provision of nursing care
Code of Ethics
Value statement 2
• Nurses accept the rights of individuals to make informed
choices in relation to their care
Code of Ethics
Value Statement 3
• Nurses promote and uphold the provision of quality nursing
care for all people
Code of Ethics
Value Statement 4
• Nurses hold in confidence any information obtained in a
professional capacity, use professional judgment where there
is a need to share information for the therapeutic benefit
and safety of a person and ensure that privacy is
safeguarded
Code of Ethics
Value Statement 5
• Nurses fulfill the accountability and responsibility inherent in
their roles
Accountability and Responsibility
Accountability: the state of being answerable for one’s decisions
and actions. It cannot be delegated.
Responsibility: the obligation that an individual assumes when
undertaking to carry out planned/ delegated functions. The
individual who authorizes the delegated function retains
accountability
Code of Ethics
Value Statement 6
• Nurses value environmental ethics and a social, economic and
ecologically sustainable environment that promotes health
and well being
Code of Professional
Conduct
Code of Professional Conduct
• Identifies the minimum requirements for practice in the
profession, and focuses on the clarification of professional
misconduct and unprofessional conduct.
• The two Codes, together with published practice standards,
provide a framework for nursing.
The Code of Professional Conduct
The purpose of the Code of Professional Conduct for nurses in
Australia is to:
• Set an expected national standard of conduct for the
nursing profession
• Inform the community of the standards &
• Provide consumer, regulatory, employing and professional
bodies with a basis for decisions regarding standards of
professional conduct
Code of Professional Conduct
A nurse must:
• Practice in a safe and competent manner
• Practice in accordance with the agreed standards of the
profession
• Not bring discredit upon the reputation of the nursing
profession
• Respect the dignity, culture, values and beliefs of an
individual and any significant other person
Code of Professional Conduct
• Support the health, well being and informed decision making
of an individual
• Promote and preserve the trust that is inherent in the
privileged relationship between a nurse and an individual,
and respect both the person and property of that individual
Code of Professional Conduct
• Treat personal information obtained in a professional
capacity as confidential
• Refrain from engaging in exploitation, misinformation and
misrepresentation in regard to health care products and
nursing services
Competencies
• There are professional and ethical competency units
within the ANMC Enrolled Nurse Competencies
which are endorsed by the Nurses Board.
• Enrolled nurses are expected to function in
accordance with legislation, policies and procedures
affecting nursing practice
• They are expected to conduct nursing practice in a
way that can be ethically justified
Professional Competence
• Professionals are expected to internalise the standards of the
profession that guide their day- to- day work
Is it lawful to disguise medication in
the patient’s food?
• Ethical issues breach of trust?????
• Legal issues duty of care?????
• Does it matter if it is medication for a physical or
psychological ailment?
Linda Saunders 7/12/04
Unclear……..
• Should not be a practice adopted to meet time issues
associated with inadequate staff levels
• Ultimately may meet duty of care
• Should be open and transparent
• Discuss with next of kin/care team
• Formalize as part of the care plan,
• Sets a standard of care for that person
Linda Saunders 7/12/04
Case scenarios
• A law student left arm was amputated after 03 of applying
POP plaster .
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