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Professional Issues CEN Study Guide
Nurse
Ethical dilemmas
Ethical principles in clinical practice include:
- Fidelity - This refers to loyalty and faithfulness to one’s commitments and responsibilities. In clinical practice, fidelity means keeping promises and maintaining a level of trust with patients. Confidentiality is a separate principle and specifically refers to keeping patient information private. This principle is violated when patient information is shared with third parties without consent.
- Veracity - This means truthfulness. Emergency nurses should provide patients with information for informed consent.
- Autonomy - Patients have the final say in their treatment. Autonomy and informed consent require educating patients about conditions, treatment indications, side effects and complications.
- Beneficence - Health workers should act in the patient’s best interest.
- Nonmaleficence - Health workers should not harm patients intentionally or unintentionally. This principle addresses negligence and malpractice.
- Justice - Health workers must treat all patients fairly, impartially and without bias based on race, religion, sexual orientation or gender.
Evidence-based practice
This approach uses research evidence, patient values and clinical expertise for clinical practices. It aims to improve patient outcomes. The steps include:
- Formulate valid clinical questions.
- Conduct research.
- Evaluate evidence.
- Integrate evidence into practice.
- Assess patient outcomes.
Impaired nurse and drug diversion
Drug diversion is the abuse or unlawful distribution of prescription medication. Addiction is the most common reason nurses divert drugs, but medications may also be diverted for sale or use by others. Common categories of diverted drugs include opioids, benzodiazepines, antipsychotics, and amphetamines.
Drug diversion usually occurs via one of the following methods:
- Taking unused medications (particularly by ordering excessive PRN drugs)
- Not administering drugs to patients or administering a substitute
Drug diversion presents a threat to patient safety. Using drugs at work may impair the nurse’s job performance, and patient comfort and health are at risk if drugs are not administered properly.
Nurses should follow facility policy for reporting suspected drug diversion and impaired nurses. Management is obligated by law to report drug and alcohol abuse to the state board of nursing; in most states, they are also obligated to report to local law enforcement. Most states offer protection and rehabilitation for nurses that self-report drug and alcohol abuse.
Workplace Violence
According to OSHA, workplace violence includes both threats and acts of physical or mental abuse during working hours or within the health care facility. Workplace violence may include harassment, intimidation, and threatening disruptive behavior.
Violence includes behaviors like verbal assault and physical striking. Even if no injury results from such behaviors, they are still considered violent.
Workplace violence is not limited to onsite workers. Patients, visitors, vendors, or any other individual or group that is connected with the facility can be the perpetrators or victims of workplace violence.
Workplace violence can sometimes be prevented before it starts. Some guidelines for prevention include:
- Read and understand the facility's workplace violence policies and procedures.
- Participate in training and education on violence awareness.
- Immediately report any suspected or known workplace violence.
- Do not accept workplace violence as a normal occurrence in the healthcare environment: develop zero-tolerance policies.
- Be aware of exits, emergency phone numbers, and unit safe rooms.
- Use screening tools to identify violent behaviors early on.
Sometimes workplace violence cannot be avoided. Still, de-escalation methods to decrease the likelihood of severe violence may be used in some situations.
A potentially violent individual typically exhibits five types of behaviors:
- Anxiety
- Defensiveness
- Verbal Threats
- Physical Threats
- Assault
Early intervention may be possible for an individual exhibiting anxiety and/or defensiveness.
De-escalation tactics for individuals demonstrating anxiety and defensiveness include:
- Using nonjudgmental and empathetic language
- Keeping a safe distance from the patient
- Discussing feelings
- Setting limits and expectations for appropriate behavior
- Allowing the patient time for quiet reflection and to make decisions
If the nurse feels unsafe or threatened, or if a person’s behavior has escalated to verbal threats, the nurse should call for help per facility policies (e.g., code gray, behavioral alert). This indicates a violent or dangerous situation and alerts security and coworkers.
Any experienced or witnessed incident of violence or threat of violence must be reported to management.
- Report violent incidents to local authorities per state laws.
- Offer support to coworkers to create a culture that encourages voluntary reporting,
Stress Management
- ED nurses work in a high-stress environment and are exposed to many difficult and emotionally disturbing situations.
- Compassion fatigue occurs with repeated exposure to situations involving traumatized, vulnerable, or distressed individuals. The caregiver may feel pain, distress, and suffering similar to what the patient is exhibiting,
- Moral distress is when the nurse’s personal beliefs, morals, and perceived obligations clash with the ethical duties they encounter while caring for others,
- Both compassion fatigue and moral distress can lead to depression, fatigue, burnout, and post-traumatic stress disorder.
Potential triggers of compassion fatigue and moral distress include:
- end-of-life care
- a futile care
- inappropriate uses of staffing and supply resources
- inadequate pain relief
- false hope
- communications that give false hope
Working in the fast-paced environment of the ED exacerbates compassion fatigue and moral distress due to many factors:
- inadequate staffing
- working overtime
- high-stress situations
- influxes of patients
Nurses often express concern that patients do not receive appropriate or adequate care. Furthermore, not knowing the patient's outcome once they are admitted to the facility or discharged can lead to unresolved questions and stress.
Symptoms of stress include:
- Sleep disturbances
- Emotional unbalance
- Difficulty making decisions
- Self-isolation
- Emotional and physical fatigue, lethargy
- Lack of interest in previous hobbies and enjoyable activities
- Impulsive behaviors
- Alcohol and drug abuse
- Blaming self and others
The nurse can take personal steps to manage stress. Similarly, the healthcare facility may implement systemic changes for stress management.
Personal methods of stress management include:
- Discuss feelings with others
- Seek assistance, if needed (psychiatric, psychological, counseling)
- Participate in regular exercise
- Manage stress with healthy behaviors
Systemic methods of stress management include:
- Implement healthy work environment initiatives
- Consult the ethics committee for guidance and advice when encountering moral distress situations
- Management may consider increasing staff during busy times, rotating staff to ensure breaks are taken, and staff debriefing after code situations.
Just Culture
Just Culture refers to an environment of shared responsibility. Its purpose is to:
- Determine the systematic reasons for undesirable events
- Adjust systems to promote safety
Rather than blaming an individual for a systems error, the organization seeks to improve the system to prevent the error from reoccurring and to improve quality and patient safety.
Employees can report safety concerns in a nonpunitive way and even anonymously.
All employees, management, and administration can access a computer reporting system.
Reports, often called variances, may be logged under the employee’s name or ID, or completed anonymously.
Staff are encouraged to report:
- Errors
- Complications
- Sentinel Events
- Safety Concerns
When completing a variance, employees must answer questions about the event, including:
- Time
- Place
- Staff Involved
- Whether A Patient Was Affected
- A Description Of What Occurred
Variances are then automatically sent to the involved managers for review. The review process generally involves departments beyond the home unit.
Patient
Discharge Planning
- In the ED, discharge planning generally involves arranging for follow-up care either with primary care services or specialty care consultations.
- Patients discharged from the ED are considered stable and should not require extensive discharge planning services.
- Care coordination is the organization of patient care activities between two medical entities (ED and primary care, community care, etc.).
- Effective care coordination can help prevent overreliance on ED and urgent care settings.
- Depending on the patient's diagnosis, discharge planning is effective in the early stages if patients are being admitted to the facility.
The ED nurse should report to the unit nurse any social or economic concerns that may impact a patient's care:
- Lack Of Insurance
- Homelessness
- Living Alone
Patients with new diagnoses (like MI, CHF, COPD) should receive educational pamphlets that describe the disease, treatment, and prognosis to the patient and family.
When concerns of patient care beyond the facility are expected, consultations to rehabilitation, dietary, social services, and other specialty services are better facilitated early on.
The ED nurse should consider potential consultation needs and query providers for orders as soon as possible.
Palliative Care
Palliative care is for patients whose serious illness limits their daily lives. Pal¬liative care focuses on improving patients’ quality of life and alleviating their pain and symptoms. It can be administered at any age and phase of a disease and may last the duration of the patient’s life.
The conditions with the highest rates of palliative care include:
- Cardiovascular disease
- Ccancer
- Chronic respiratory diseases
- AIDS
- Diabetes
Unlike hospice care, active treatment may continue in palliative care,
Palliative care may be initiated for people at any age and at any stage of a chronic, severe disease or illness.
The palliative care team is multidisciplinary and applies a holistic approach to manage the physical, mental, emotional, social, and spiritual needs of the patient.
Palliative care may include any intervention that promotes an improved quality of life based on patient presentation. It is aimed at alleviating or improving:
- Pain
- Depression and anxiety
- Dyspnea
- Nausea/vomiting
- Nutritional intake a ROM and mobility
- Social support (e,g., group therapy)
Patient Safety
The ED is a high-risk environment. Special considerations and skills are needed to ensure that patients and staff remain safe and to treat and prevent emergent conditions. Following safety protocols and national guidelines prevents some of the most common patient safety concerns.
Potential patient safety issues in the ED include patient falls, medication errors, and the safety of moderately ill patients in waiting rooms.
Preventing falls in the ED is a difficult endeavor due to the chaotic and fast-paced nature of the environment. Communication with the patient, provision of call lights, nonslip footwear, and hourly rounding are good ways to mitigate the risk of patient falls. Bed and chair alarms should be used when appropriate.
Medication errors in emergency situations or resuscitation efforts are more likely to occur in the ED. Drills and practice in these situations allow the nurse to be confident and efficient in administering emergency drugs. Use facility safety checks and barcode medication administration per protocol.
ED overcrowding can lead to poor patient outcomes in the waiting room before a patient can be seen. Hourly rounding and reassessment of patients can prevent deterioration or waiting room deaths.
Follow SBAR recommendations to ensure that adequate and appropriate handoffs are given during shift change and when the patient is admitted to the facility.
Develop protocols to enhance patient safety by:
- Enforcing standing orders for time-sensitive conditions that require urgent treatment (e.g., stat ECG for chest pain)
- Decreasing time to treat
- Initiating testing and treatment early on
- Creating a safety checklist
- Using translation services when language barriers are identified
- Ensuring staffing matrix is sufficient for patient load
- Starting sepsis protocol while the patient is in the ED
Transition Of Care
Transition of care is the process of moving patients from one care setting to another. Key considerations for transition of care include:
- Accessibility of services
- Information sharing and communication
- Community partnerships
- Care coordination
- Health care utilization and costs
- Safety
SBAR (Situation, Background, Assessment, and Recommendation) handoff is a reporting tool used during shift change, when a patient is being admitted, or when an acute change in the patient s condition needs to be communicated to the care team.
- Situation: nurse's name, patient's name and location, any current problems
- background: diagnosis, history, and current care plan
- Assessment: relevant vital signs and diagnostic testing
- Recommendation: recommendations for further testing, changes to care plan, or transfers
Abuse And Neglect
Abuse is the intentional infliction of injury on another person. Neglect occurs when a person fails to meet the needs of a someone in their care; this may be a child, an elderly person, or a person with disabilities.
Child abuse and neglect, intimate partner violence, and elder neglect may lead victims to seek acute care. Nurses must be able to recognize the signs of abuse and neglect during assessment. These include:
- Bruises, lacerations, burns, or fractures
- Injuries inconsistent with the provided history
- Patient anxiety around caregivers or partners
- Patients expressing concerns about confidentiality
- Caregivers or partners who stay very close to the patient or interfere with care
There are laws to protect vulnerable populations unable to protect themselves or adequately meet their own essential needs. Covered entities are required to report known or suspected cases of child (under 18) or elder (over 60) abuse or neglect to social services or another agency designated to handle this issue.
Most states also have laws protecting individuals aged 18 - 59 with known disabilities that prevent them from caring for or protecting themselves. The offenses that must be reported include physical, emotional, psychological, financial, and sexual abuse or exploitation; neglect; and abandonment.
The requirements for reporting intimate partner violence vary from state to state. While it is mandatory for healthcare providers to report suspected cases to the police, the specifications of who is a mandatory reporter and what must be reported vary.
When signs of abuse or neglect are seen, the ED nurse should follow the facility’s reporting policy.
Human Trafficking
Human trafficking is the illegal exploitation of human beings for monetary or sexual gain. According to the US Department of Homeland Security, trafficking in persons means using “force, fraud, or coercion to obtain some type of labor or commercial sex act." The main types of human trafficking are forced labor, domestic servitude, and commercial sex acts. Human trafficking is against the law.
Sex trafficking includes inducing people to perform commercial sexual acts. If the victim is under 18, no force or coercion need be used for the act to be considered trafficking. Forced labor includes the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services. Traffickers use force, fraud, or coercion to subject people to involuntary servitude, peonage, debt bondage, or slavery.
Certain conditions may make an individual more vulnerable to becoming a trafficking victim:
- Poverty
- Lack of education
- Living in a rural location
- Being a migratory worker
- Belonging to an Indigenous tribe
- Belonging to the LGBTQ community
- Lack of social support system, especially among girls aged 12 - 16
- Disability
- History of abuse
Nurses should be alert to signs of human trafficking, including:
- Bruising, cuts, burns, and other evidence of unexplained injuries
- Depression and anxiety
- Suicidal thoughts and self-harm behavior
- Flat affect a PTSD
- Alcohol and drug abuse
- Answers to health questions that do not make sense or seem scripted
- Fearful behavior with lack of eye contact
Any signs or suspicions of abuse of elders, minors, or incompetent individuals should be reported per state law and hospital policy.
- If patients are in immediate or emergent danger, contact law enforcement per facility policy.
- If a patient discloses that they are being trafficked:
- The nurse should inform their supervisor.
- The patient should be encouraged to contact the National Human Trafficking Resource Center (NHTRC) hotline at 1-888-373-7888 and be given privacy to do so.
- Document all information in cases of suspected trafficking.
System
Delegation Of Tasks To Assistive Personnel
Delegation means empowering another person with responsibility to take an action. Certain tasks in the ED may be delegated to assistive personnel, depending on their scope of practice.
Local organizational policies, state nurse practice acts, and professional association practice guidelines all govern delegation of tasks in the health care setting.
Registered nurses in the ED may delegate tasks to the following licensed personnel:
- Paramedics and EMTs working in the ED
- LPNs/LVNs
- Medical assistants
- Nursing assistants
- Technicians
Tasks must be delegated under the following conditions:
- The nurse ultimately remains responsible for the completion of the task and its outcome.
- Delegation should account for the scope of practice and, to the extent possible, the skills and abilities of the individual to whom the task is delegated.
Disaster Management And Mass Casualty
Disaster management in the context of emergency nursing includes considerations for mass casualty incidents, natural disasters, pandemic/epidemic illness, and decontamination of patients. Disaster preparedness is usually managed in the form of large-scale drills or tabletop exercises to determine how to mitigate weaknesses and identify needs in disaster management plans.
Many organizations use the incident command system (ICS) promoted by FEM A to manage disaster situations. Each role in the ICS is preassigned and drilled in preparation for disaster events. Organizations may customize the hierarchy below the general staff to fit the needs of their own system.
The following are four steps to disaster management and preparedness.
- Mitigation: Identify vulnerabilities to threats or weaknesses in current plans.
- Preparedness: Develop mutual aid agreements, create disaster management plans, determine supply thresholds and needs, consider stockpiles, and establish a command-and-control structure.
- Response: Warn (notify), isolate (during the disaster), and rescue (following the disaster).
- Recovery: Inventory supplies and resources, relieve staff members present during the isolation phase, incorporate records into the EMR, implement CISM program if needed, and activate employee assistance programs if needed.
Mass casualty incidents (MCls) are characterized by a rapid influx of patients that overwhelms the resources available in the ED, resulting in the activation of a contingency plan to bring more resources (staff, supplies, etc.) where they are needed. Examples of MCIs include mass shootings, sudden onset of contagious disease (e.g., COVID-19 pandemic), MVCs involving buses or a large number of vehicles, train and airplane accidents, and biolog¬ical/chemical accidents or attacks.
Decontamination must be performed by trained or certified individuals with a strong working knowledge of contaminants. Decontamination areas must be set up a good distance from any entrance into a hospital to avoid cross-contamination of the area and building.
- The hot zone of care is the point of entry to the decontamination process following an incident.
- Patients triaged as immediate, delayed, or non-ambulatory will be decontaminated first.
- Patients are triaged in the hot zone and have their clothes removed as they approach the warm zone.
- The warm zone is where active decontamination occurs. Decontam¬ination usually includes the use of water, but this will depend on the chemical, biological, or radioactive agent the patient is exposed to.
- The cold zone is the point of exit from the decontamination area. The patient enters the cold zone and may be treated onsite or transported to an appropriate level of care.
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