Choose one of the articles below, and address the essay prompt associated with it. You will need to log in to the WCU library to access the full article. Park, M. (2009). Ethical issues in nursing pra

Choose one of the articles below, and address the essay prompt associated with it. You will need to log in to the WCU library to access the full article. Park, M. (2009). Ethical issues in nursing pra
Journal of Nursing Law, Volume 13, Number 3, 2009 68 • Copyright © 2009 Springer Publishing Company DOI: 10.1891/1073-7472.13.3.68 Ethical Issues in Nursing Practice Mihyun Park, MSN, RN Nurses play a role as advocates to assist patients and families struggling with complex information and difficult decisions. In particular, the fact that nurses encounter clinical situations that require ethical judgment highlights the need for nursing staff to gain knowledge and expertise in deliver- ing care in an ethical manner. In this study, through reviewing empirical studies of hospital-based nurses’ experiences, the author identified the ethical issues that nurses frequently face and the approaches that they have taken to solving them. The findings can serve to intensify the awareness of the ethical issues in both clinical and educational areas. Keywords: ethical issues; nursing practice; education; hospitals A dvances in medical technology allow for bet- ter recovery for critically ill patients and dramatically extend the human life span. However, while advances bring benefits to patients and families, they simultaneously raise moral and ethical issues regarding respect for patient integrity and autonomy, soaring medical costs, quality care, and end-of-life decision making (Scanlon & Fleming, 1990; Wright, Cohen, & Caroselli, 1997). As the largest group of health care providers, nurses are frequently placed in unique positions to assist patients and families struggling with complex information and dif- ficult decisions (Briggs & Colvin, 2002). The fact that nurses encounter clinical situations that require ethi- cal judgment highlights the need for nursing staff to gain knowledge and expertise in delivering care in an ethical manner. Reporting the lack of ethical confidence among newly graduated nurses, nursing ethics researchers have emphasizes the importance of having well- educated and well-qualified nurses who know how to find feasible solutions to ethical problems (Bunch, 2001; Woods, 2005). Although nursing schools have become more concerned with the ethical development of their students, researchers point out that education has not reflected reality and does not prepare newly qualifying nurses to deal effectively with a variety of ethical situations in the health care setting ( Woods, 2005). The traditional ethics education has tended to emphasize the acquisition of philosophical and theoretical knowledge and has created a gap between theory and practice ( Woods, 2005). New approaches are needed for teaching nursing ethics pragmatically. The nursing ethic as a dynamic standard for nurses’ professional moral behavior should address ethical issues confronted by nurses (Omery, Henneman, Bil- let, Luna-Raines, & Brown-Saltzman, 1995). Therefore, knowledge about specific nursing ethical issues found in the health care setting and understanding the impact of these issues on practice will be essential, pragmatic parts of nursing ethics education. That is, the ethical issues are subjects that should be dealt with in ethics education for nursing students before entering in nurs- ing practice. Thus, identifying what issues should be dealt with in classes is needed. Researchers have tried to identify ethical issues that nurses confront in the clinical area since Vaughan’s (1935) study. The earliest study of ethical issues in nursing practice (Vaughan, 1935) identified 2,265 ethical issues based on the diaries of 95 nurses that recorded ethical issues. Since this study, many other studies have been focused on ethical issues that affect the profession of nursing and the everyday practice of individual nurses using qualitative methodolo- gies. In a review study, Christensen (2002) identified the ethical and legal issues that oncology nurses in hospitals face: (a) advance directives, ( b) do-not- resuscitate orders, (c) documentation and patient privacy, (d) informed consent, (e) medication errors, and (f ) pain management. A systematic analysis Park Ethical Issues in Nursing Practice 69 study of nurses’ ethical conflicts identified each main ethical issue in a particular role or setting (Redman & Fry, 2000). Examples were (a) harm/good of life- prolonging aggressive therapies (intensive care unit); ( b) inadequacy of resources for care (administration); (c) undertreatment, consent, and refusal of treatment (oncology); (d) disagreement with quality of medical care (diabetes educators); and (e) protection of child’s rights (pediatric nurse practitioner). However, a sys- tematic review of ethical issues encountered by nurses in current practice is rarely found. The purpose of this study is to review the empiri- cal studies of hospital-based nurses’ experiences with ethical issues to identify (a) the ethical issues nurses face and ( b) the approaches they have taken to solving them. METHODS This article reviewed quantitative studies of hospital- based nurses’ experiences with ethical issues. To be included in this review, a publication was to have reported the findings from a research project studying nurses’ experiences. The integrative review included the reports of primary research studies that were pub- lished in the English language from 1990 and 2007. This study began with a search of multiple library databases, including PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health (CINAHL), and ISI Web of Knowledge, to identify research related to ethical issues that nurses face. Key words used in the search process were “nursing ethics” and “issue” and/or “problem.” Additional literature was identified by reviewing the reference lists of journal articles identified during the literature review. Examination of the published abstracts and studies resulted in a decrease of the number of studies included in the first sampling because studies that did not match the project criteria were excluded ( n = 25). This study was limited to hospital-based research and settings in the United States. Most studies in special clinic areas dealt with a more specific ethical issue or conflict situa- tion. Therefore, these articles were excluded. However, this review included the studies done in operating room areas and collected data from registered nurses in a local area because the studies dealt with more general ethical issues encountered by perioperative nurses or registered nurses with a large sample size. One article that collected data from directors of nursing in hos- pitals was included because the directors explained ethical issues not that they faced but that were faced by staff nurses. Therefore, through the second review, the researcher excluded the articles that did not match the purpose of this project. This review classified the ethical issues reported by each study into three categories of the Ethical Issues Scale (EIS): end-of-life treatment decisions, patient care issues, and human rights issues. Fry and Damrosch (1994) developed the EIS in a study of Maryland nurses. The EIS was validated with a sample of New England registered nurses currently in practice (Fry & Duffy, 2001). The scale described the full range of ethical issues experienced by nurses in current practice. The 32-item scale represented three conceptual categories of ethical issues: end-of-life treatments, patient care, and human rights (Fry & Duffy, 2001) (see Table 1). The end-of-life treatment category was defined as issues about death or the dying process and included 13 issues. The patient care category addressed issues about how patients receive or do not receive quality nursing or health care (14 items). The human rights category was defined as issues concerning the rights of nurse, patients, and family members (five items). The EIS pro- vides information about the full range of ethical issues of registered nurses in active practice experience. The reliability and validity of the EIS have been validated through a study with a large RN sample ( n = 2,090) and nurses with expertise in bioethics (Fry & Duffy, 2001). RESULTS Twenty-five studies were identified through the first review process, and 11 studies met the inclusion crite- ria. All studies used a descriptive research method with survey instruments. Articles reviewed were classified into two settings: hospital and operating room. One article collected data from registered nurses in Mary- land; this article was integrated to hospital setting data. The ethical issues reported in reviewed studies were divided into three categories (end-of-life treatment decisions, patient care issues, and human rights issues) in the EIS. This review described disturbing ethical issues that were encountered by nurses separated from the frequent ethical issues. This study identified the top five frequent ethical issues and disturbing ethical issues reported in each article and then integrated and analyzed these issues. Furthermore, this study identi- fied the approaches that nurses have taken to solve the ethical issues and the resources that nurses frequently used to get help and information. Ethical Issues As shown in Table 2, the most of frequent ethical issues faced by nurses related to patient care issues and human 70 Journal of Nursing Law Vol. 13, No. 3 TABLE 1. The Ethical Issues Scale Component 1: End-of-life treatment decisions Prolong dying process with inappropriate measures Treatment or nontreatment despite patient or family wishes Use or removal of life support including nutrition and hydration To resuscitate or not to resuscitate Treatment or nontreatment of very disabled infant, child, adult Not considering quality of patient’s life Acting against your own personal or religious views Acting against patient’s personal or religious values Determining when death occurs Organ transplantation, or organ or tissue procurement Over- or underuse of pain management Ordering too many or too few procedures, tests, etc. Participation or refusal to participate in euthanasia or assisted suicide Component 2: Patient care issues Staffing patterns that limit patient access to nursing care Child or spousal or elderly or patient abuse or neglect Allocation of resources (human, financial, equipment) Implementing managed care policies threatening quality of care Breaches of patient confidentiality or privacy (e.g., HIV status) Irresponsible or unethical or incompetent or impaired colleague Ignoring patient or family autonomy Patients or families uninformed or misinformed about treatment, prognosis, medical alternatives Rights of minors versus parental rights Discriminatory treatment of patients Unsafe equipment or environmental hazards Conflict in nurse or doctor relationship (or other professional relationship) Reporting unethical or illegal practice of health professional or health agency Implementing managed care policies threatening availability of care Component 3: Human rights issues Use or nonuse of physical or chemical restraints Issues involving advance directives Protecting patient rights and human dignity Informed consent to treatment Providing care with possible risk to RNs’ health (e.g., TB, HIV, violence) Note. From “The development and the psychometric evaluation of the Ethical Issues Scale,” by Fry and Duffy, 2001, Journal of Nursing Scholarship, 33(3), p. 276. rights issues rather than end-of life issues. The most frequent issues were founded in patient care issue cat- egory. Of patient care issues that nurses encountered, staffing patterns that limit patient access to nursing care ( n = 6) was the most frequent ethical issue. In addition, nurses frequently encountered patient care issues such as conflict in nurse or doctor relationship ( n = 4), alloca- tion of resources (human, financial, equipment) ( n = 4), patient confidentiality or privacy ( n = 4), and incom- petent or impaired colleague ( n = 4). In human rights issue category, the following three items were identi- fied as the most frequent ethical issues: (a) protecting patient rights and human dignity ( n = 5), (b) providing care with possible risk to RNs’ health ( n = 5), and (c) informed consent to treatment ( n = 4). When this review separated the setting into a gen- eral hospital versus operating room area, studies done in a general hospital setting identified other frequent ethical issues: dealing with an irresponsible or unethi- cal or incompetent or impaired colleague (Berger, Sev- erson, & Chvatal, 1991; Cook, Hoas, & Joyner, 2000), end-of-life care (Killen, 2002; Scanlon, 1990, 1994), and pain management (Omery et al., 1995; Scanlon, 1994). Nurses in hospitals reported that they experienced fre- quent ethical problems related to patient confidential- ity or privacy issues as well as staffing patterns issues. TABLE 2. Frequent Ethical Issues Articles SettingEnd-of-Life Treatment Decisions Patient Care Issues Human Rights Issues Berger et al. (1991)A hospital (U) Prolonging life with heroic measures a Staffing patterns, inappropriate allocation of resources, dealing with situations where patients are discussed inappro- priately, dealing with colleagues’ irresponsible activity Cook et al. (2000) Hospitals (R) Staffing patterns, patient family requesting more aggressive treatment options, a patient has unclari- fied confusing or no-code orders, colleagues are discussing patients inappropriately, dealing with an incompetent colleague Fry and Damrosch (1994)RNs in Mary- landQuality of patient life Staffing patterns, nurse–physician relationships Providing care that places the nurse at risk a Jenkins et al. (2006)OR in army Staffing patterns, conflicts in the nurse–physician relationship a Providing care with risk to self, protecting patient rights and human dignity Killen et al. (1996)OR Staffing patterns, nurse–physician relationship Providing care with risk to self, a informed consent, patient advocacy Killen (2002) OR End-of-life care, abortion issues Quality of care, truth telling, abuse of children/older people, confidentiality, privacy Informed consent, a HIV/ AIDS care, clinical safety King and Miskovic (1996)OR Staffing patterns, a allocation of resources, patients’ autonomy/advocacyInformed consent, occu- pational risk, patient self- determination act Omery et al. (1995)A hospital (U) Pain relief/ management a Dealing with difficult patients, patient–physician– nurse relationship, care of noncompliant patient, cost of care to the patient Scanlon (1990) Hospitals (U) Do not resuscitate a death and dying.Professional practice issues, AIDS, allocation of resourcesPatients’ rights, AIDS Scanlon (1994) Hospitals in 50 statesEnd-of-life care, pain managementCost of containment issue, a confidentiality, incompetent, unethical, or illegal practices of colleagues Schroeter (1999) OR Impaired provider/potential for unsafe practice, misrepresentation by care provider, provider judgment/competencyConsent/advocacy, a disrespect for patient Note. U = urban area; R = rural area; RN = registered nurses; OR = operating room.aMost frequent item in the article. 72 Journal of Nursing Law Vol. 13, No. 3 TABLE 3. Rankings of Frequent Ethical Issues and Disturbing Ethical Issues Frequent Ethical Issues in All Reviews (N)Frequent Ethical Issues in Hospital Setting (N)Frequent Ethical Issues in Operating Room (N)Disturbing Ethical Issues (N) Staffing patterns that limit patient access to nursing care(6) Patient confiden- tiality or privacy (4) Protecting patient rights and human dignity(4) Prolong dying process with inappropriate measures(4) Protecting patient rights and human dignity(5) Staffing patterns that limit patient access to nursing care(3) Informed consent to treatment(4) Child or spousal or elderly or patient abuse or neglect(3) Providing care with possible risk to RNs’ health (5) Allocation of resources (human, finan- cial, equipment)(3) Providing care with possible risk to RNs’ health (3) Staffing patterns that limit patient access to nursing care a (2) Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)(4) Irresponsible or unethical or incompetent or impaired col- league(3) Staffing patterns that limit patient access to nursing care(3) Acting against your own personal or reli- gious views(2) Allocation of resources (human, finan- cial, equipment)(4) Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)(2) Conflict in nurse or doctor relationship (or other profes- sional relationship)(2) Irresponsible or uneth- ical or incompetent or impaired colleague a (2) Informed consent to treatment(4) Providing care with possible risk to RNs’ health (2) Providing care with possible risk to RNs’ health a (2) Irresponsible or unethical or incompetent or impaired col- league(4) End-of-life deci- sion(2) Treatment or nontreat- ment despite patient or family wishes(2) Patient confiden- tiality or privacy(4) Pain manage- ment(2) aFrequent ethical issues included in the disturbing ethical issues. In contrast, this review found that perioperative nurses experienced more frequent ethical issues related to protecting patient rights and human dignity issues and informed consent than other issues (see Table 3). Five of the reviewed articles reported disturbing eth- ical issues separately from the frequent ethical issues faced by nurses. Although these ethical issues would not frequently happen in their practice areas, nurses reported to be disturbed a great deal or quite a bit when these occurred. As shown in Table 3, the disturb- ing issues related to patient care issues and end-of-life issues. The disturbing ethical issues were (a) prolonging the dying process with inappropriate measures ( n = 4), (b) child, spousal, elderly, or patient abuse or neglect ( n = 3); (c) staffing patterns that limit patient access to nursing care (Berger et al., 1991; Jenkins, Elliott, & Harris, 2006); (d) acting against your own personal or religious views (Berger et al., 1991; Cook et al., 2000); (e) irresponsible, unethical, incompetent, or impaired colleague (Jenkins et al., 2006; Killen, Fry, & Damro- sch, 1996); (f) providing care with possible risk to RNs’ health (e.g., TB, HIV, violence) (Fry & Damrosch, 1994; Killen et al., 1996); and (g) treatment or nontreatment despite patient or family wishes (Berger et al., 1991; Cook et al., 2000) (see Table 4). The most of disturbing issues were not frequent ethical issues experienced by nurses. Disturbing issues often related to end-of-life issues: prolonging the dying process with inappropriate measures, acting against your own personal or religious views, and treatment or nontreatment despite patient or family wishes. Nurses reported being disturbed when patient abuse or neglect Park Ethical Issues in Nursing Practice 73 TABLE 4. The Most Disturbing Ethical Issues Articles SettingEnd-of-Life Treatment Decisions Patient Care IssuesHuman Rights Issues Berger et al. (1991) A hospital (U) Treatment despite patients’ objectives, prolonging life with heroic measures, acting against personal principlesInadequate staffing patterns, a incidents of patients’ abuse Cook et al. (2000) Hospitals (R) Acting against personal principles, a prolonging life with heroic measuresPatient family requesting more aggressive treat- ment options, cost- containment issues that threaten quality if care, treatment or nontreatment despite patient or family wishes Fry and Damrosch (1994)RNs in Maryland Prolonging life with extraordinary measures, a quality of patient lifeCost-containment issues that threaten quality of care, child/spousal / elderly/patient abuse or neglectProviding care with risk to self a Jenkins et al. (2006)OR in army Dealing with incom- petent or impaired colleagues, a conflicts in the nurse–physician relationship, staffing patterns, unsafe equipment and /or environment hazards Killen et al. (1996) OR Prolonging life with extraordinary means, a treatment over family objectivesIrresponsible/incom- petent colleagues, patients and families who are uninformed or misinformed about treatment plans, prognosis, child/other abuseProviding care with risk to self Note. U = urban area; R = rural area; RN = registered nurses; OR = operating room.aMost frequent item in the article. of patient care issues occurred. Furthermore, the review found that the staffing pattern and incompetent, impaired colleagues issues and providing care with pos- sible risk to RNs’ health were disturbing issues as well as frequent issues that were faced by nurses. Approaches/Resources This study also reviewed the approaches and resources that nurses have taken to solving ethical issues. Four articles reported that most nurses used their own per- sonal values to solve ethical issues (Berger et al., 1991; Cook et al., 2000; Killen et al., 1996; Schroeter, 1999) (see Table 5). In addition, most nurses discussed ethical problems with nursing peers (Berger et al., 1991; Cook et al., 2000; Jenkins et al., 2006; Killen et al., 1996; Scanlon & Fleming, 1990). One study reported that 68% of respondents reported talking to a higher administra- tive authority (e.g., managers, supervisors, or directors) TABLE 5. Approaches and Resources for Ethical Issues Articles Setting Sample Sample Size (N)Measures Approaches/Resources EN Comments Berger et al. (1991) A hospital in an urban areaNurses 52 A questionnaire (Ethical Issues in Nursing )Own personal values (88%) Nursing colleagues (97%)(+) Recommendation: nursing ethics rounds, educational opportunities/programs, a shared governance model Cook et al. (2000) 21 hospitals in rural areaNurses 204 A 14-page surveyOwn personal values (48%) Nursing colleagues (87%), nursing leadership (77.4%), physicians (70%), clergy (7%)(+) Education topics: profes- sional responsibilities, infor- mation on patient rights, privacy and confidentiality, information regarding truth telling Fry and Damrosch (1994)RNs in MarylandNurses 462 The survey instrument Nursing peers (71%), nursing leadership (51%), physicians (56%), other professionals (39%), ethics committee (11%)(+) Education topics: empower- ment of nurses, content/ interpretation of nurses’ ethical codes, care of HIV/ AIDS patients, treatment/ nontreatment of the dying and/or elderly, quality of life, use/removal of life support systems, profes- sional responsibilities, care of dangerous and/or offensive patients, ethical decision making, pain man- agement, moral develop- ment/ reasoning Jenkins et al. (2006)Army in United StatesCRNAs ANC = 74; DAC = 22 Modified Ethical Issue Scale (EIS)An informal approach Nursing peer (84.5%), nursing leadership (54.6%), ethics committee (5.2%)(+) Education topics: ethics of triage, conduct of the health care provider as a prisoner of war, the role of nurses as advocates, ethical decision making, quality of life Killen et al. (1996) OR/recovery roomPORNs 373 Pre-EIS Nurses’ personal codes of ethics Nursing peers (73%), nursing leadership (57.7%), physicians (50%), other professional (30.8%), family or friends (30.8)(+) Education topics: patient’s right to information, treat- ment of the dying and the elderly, treatment of the deformed and handicapped, pain management, patient’s right to demand or refuse treatment Killen (2002) The members of the AORNPORNs 214 A cross-sectional surveyEthical principles: auton- omy (33.8%), nonma- leficence (42.9%), fidelity (9.8%)NA Recommendation: adminis- trative support King and Miskovic (1996)The members of the AORN in BaltimorePORNs 217 Ethical Issues: A Survey of Periop- erative NurseNA (+) Recommendation: educa- tion about the American Nurses Association code of ethics Omery et al. (1995)A medical center in an urban areaNurses 794 The Ethical Issue and Resources SurveyNA NA NA Scanlon (1990) Institutions in an urban areaDirec- tors of nursing71 A questionnaire Formats addressing ethical issues in nursing: nursing meeting (66%), in-service education (18%), hospital committees (9%), individu- al discussion/consultation (9%), hospital ethics committee (9%)(+) Used ethics education methods in hospitals: orientation program (35%), continuing education programs (42%) Scanlon (1994)RNs in 50 states (hospitals)Nurses 934 A written survey Literature (44%), ethics committees (42%), continuing education (39%)(+) NA Schroeter (1999) PORNs in southeastern WisconsinPORNs 40 A descriptive self-report ques- tionnaire, a scenario-based surveyPersonal values, work experiences, nursing code of ethics, professional education A higher administrative authority (68%), direct confrontation (21%)NA NA Note. EN = education need; (+) = expressed education need; CRNAs = certified RN anesthetists; ANC = Army Nurse Corps; DAC = Department of the Army Civilian; OR = operating room; PORNs = perioperative RNs; AORN = Association of Perioperative RNs; NA = not applicable. 76 Journal of Nursing Law Vol. 13, No. 3 (Schroeter, 1999). A small percentage of responding nurses had experience consulting with ethics commit- tee (Fry & Damrosch, 1994; Jenkins et al., 2006; Scan- lon & Fleming, 1990) (see Table 4). However, one study reported ethics committees as one of main resources that nurses consider available when facing an ethical problem (Scanlon, 1994). Moreover, most of studies (n = 8) reported nurses’ educational need related to nursing ethics. In four stud- ies, the nurses indicated the need for the following edu- cation topics: (a) professional responsibility, (b) patient rights, (c) ethical code/principles, (d) treatment/non- treatment of the dying, (e) patient advocacy, (f) ethical decision making, and so on (see Table 4). DISCUSSION Most of ethical issues mentioned in the reviewed articles can be classified into three categories in the EIS: end-of-life issues, patient care issues, and human rights issues. Frequent ethical issues faced by nurses related mainly to patient care issues and human rights issues, whereas the disturbing issues frequently related to end-of-life issues. The most frequent issues are staff- ing patterns, protecting patient rights and human dig- nity, providing care with possible risk to RNs’ health, conflict in the nurse or doctor relationship, and alloca- tion of resources. The disturbing ethical issues include prolonging the dying process, child or elderly abuse (neglect), staffing patterns, acting against your own personal, and impaired colleagues. Nurses in daily practice face various ethical issues. In particular, as technology becomes more compli- cated and medical care resources become more limited, the concern over “staffing patterns” or “allocation of resources” is centered frequently on nurses, reflecting the industry-wide trend of balancing cost and quality (Killen et al., 1996). The issues are also ranked among the most disturbing issues; that is, it is not a rare event that nurses are directly involved in these most disturb- ing issues. Thus, nurses may need special support to ethically respond to the issues that are particularly dis- turbing to them. Nurses in hospitals reported that they experienced frequent ethical problems related to patient confiden- tiality or privacy. In contrast, perioperative nurses more frequently encountered ethical issues related to protecting patient rights and the human dignity issue and informed consent than other issues. The frequency of ethical issues may differ depending on the nurses’ specialty areas. Redman and Fry (2000) reported that the main ethical conflict was experienced differently by nurses in a particular role or setting. The findings indicate that ethical decision-making resources need to be made available to nurses in a specialty area in view of their higher-frequency issues. In terms of how the nurses handle their ethical issues and what resources help nurses handle these issues, most of studies show that nurses deal with ethical issues on the basis of their own values and receive guid- ance from nursing peers rather than from ethics com- mittees. The fact that nurses use their personal values most frequently to clarify ethical issues draws atten- tion to necessity of nurturing qualified nurses in ethi- cal decision making through education. Furthermore, most of the nurses in the reviewed studies recognized the necessity of ethics education related to the ethical issues that they face. Therefore, nursing education should develop pragmatic ethics programs based on the ethical issues and the needs of nurses. In particular, the frequent ethical issue should be discussed in the ethics curriculum of undergraduate programs for developing skills in recognizing and analyzing the issues. The code of ethics of the American Nurses Asso- ciation (ANA, 2001) deals with moral accountability as a nursing professional based on ethical principles. According to study findings, nurses have not recog- nized the code of ethics as their reference when ethical issues are encountered. However, nurses simultane- ously expressed education needs regarding professional ethical responsibility and ethic codes. Ethics educators in nursing programs need to explain the ANA’s code of ethics as well as ethical principles. The code of ethics will provide a guide for nurses when facing an ethical dilemma. During the process of review in this study, the reviewer did not include several articles related to specialty areas because they did not deal with ethical issues in terms of frequency. This study may not have identified all relevant studies. Furthermore, this review has limitations related to information about nurses’ eth- ical issues in other special areas, except the operating room. Therefore, the author recommends further study related to frequent ethical issues that nurses face in a particular role or setting. Future study can help nurses understand ethical issues in special areas and allows developing ethics education focused on specific issues in a particular nursing practice. Furthermore, new ethical issues in nursing are emerging with changes in our society. This study shows ethical issues frequently repeating in nursing in the past two decades and may not include some current issues. Therefore, nursing educators and researchers continuously need to update the ethical issues into nursing education. Park Ethical Issues in Nursing Practice 77 The ethical issues measured by frequency provide information about the specific ethical issues of nurses in active practice experience. Therefore, the informa- tion can serve to intensify awareness of the issues in clinical areas as well as education areas. Gilbert (1982) pointed out the identification of ethical issues as one of critical content areas in ethics education. The findings in this article can be used to design and improve eth- ics education programs for nursing students as well as practice nurses as pragmatic evidence. REFERENCES American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Silver Spring, MD: American Nurses Publishing. Berger, M. C., Seversen, A., & Chvatal, R. (1991). Ethical issues in nursing. Western Journal of Nursing Research, 13 (4), 514–521. Briggs, L., & Colvin, E. (2002). The nurse’s role in end-of-life decision-making for patients and families. Geriatric Nurs- ing, 23 (6), 302–310. Bunch, E. H. (2001). Hidden and emerging drama in a Norwe- gian critical care unit: Ethical dilemmas in the context of ambiguity. Nursing Ethics, 8 (1), 57–67. Christensen, A. (2002). Legal and ethical issues confronting oncology nursing. Seminars in Oncology Nursing, 18(2), 86–98. Cook, A. F., Hoas, H., & Joyner, J. C. (2000). Ethics and the rural nurse: A research study of problems, values, and needs. 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(1996). Ethical issues: A survey of perioperative nurses. Seminars in Perioperative Nursing, 5 (2), 84–91. Omery, A., Henneman, E., Billet, B., Luna-Raines, M., & Brown-Saltzman, K. (1995). Ethical issues in hospital-based nursing practice. The Journal of Cardiovascular Nursing, 9 (3), 43–53. Redman, B. K., & Fry, S. T. (2000). Nurses’ ethical conflicts: what is really known about them? Nursing Ethics, 7(4), 360–366. Scanlon, C. (1994, November–December). Ethics survey looks at nurses experiences. The American Nurses , 22. Scanlon, C., & Fleming, C. (1990). Confronting ethical issues: A nursing survey. Nursing Management, 21 (5), 63–65. Schroeter, K. (1999). Ethical perception and resulting action in perioperative nurses. AORN Journal, 69 (5), 991–1002. Vaughan, R. H. (1935). The actual incidence of moral problems in nursing: A preliminary study in empirical ethics (Studies in Nursing Education, Vol. II, Fasc. 2). Washington, DC: Catholic University of America. Woods, M. (2005). Nursing ethics education: Are we really delivering the good(s)? Nursing Ethics, 12 (1), 5–18. Wright, F., Cohen, S., & Caroselli, C. (1997). Diverse deci- sions: How culture affects ethical decision making. Critical Care Nursing Clinics of North America, 9 (1), 63–74 . Biographical Data. Mihyun Park, MSN, RN, is a doctoral stu- dent at the University of North Carolina, Chapel Hill, North Carolina. She is also a Catholic Sister in Sisters of Our Lady of Perpetual Help (SOLPH), South Korea. Correspondence regarding this article should be directed to Mihyun Park, MSN, RN, University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: [email protected] Copyright of Journal of Nursing Law is the property of Springer Publishing Company, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. 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Choose one of the articles below, and address the essay prompt associated with it. You will need to log in to the WCU library to access the full article. Park, M. (2009). Ethical issues in nursing pra
Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 • 3 Despite ongoing efforts to educate nurses on the law and their professional responsibilities through nursing programs and continuing education courses, the number of nurses named as defendants in malpractice actions continues to increase (Croke, 2003; Guido, 2006; National Practitioner Data Bank (NPDB) Annual Report, 2004). In 1986, The Health Care Quality Improvement Act, Title IV of P.L. 99-660, authorized the Secretary of Health and Human Services to establish and monitor a national practitioner data bank (NPDB). The mission of the NPDB is to protect the public by “restricting the ability of unethical or incompetent practitioners to move from State to State without disclosure or discovery of previously damaging or incompetent performance”(NPDB, 2004, p.10). The NPDB is a central repository receiving information from private and governmental agencies under U.S. jurisdiction. Information received by the NPDB is accessible to registered entities, such as state licensing boards and professional societies, which are eligible to query. Although patients cannot access the NPDB, health care providers listed in the NPDB can access their own information to check for misinformation. The NPDB collects information on physicians, dentists, nurses, and other health care practitioners who, as a result of judgments in malpractice suits, have entered into settlements, had disciplinary action taken against them that resulted in their licenses being revoked or suspended, had their privileges to practice limited, or had to pay monetary awards (Croke, 2003). According to the National Practitioner Data Bank 2004 Annual Report , since its inception in 1990 and continuing through 2004, there have been approximately 5,001 malpractice claims assessed against all types of registered nurses (RNs). The NPDB established the following malpractice reason categories for reporting numbers of nursing malpractice payments: Anesthesia related Behavioral health related Diagnosis related 1. 2. 3. Equipment or product related IV or blood products related Medication related Monitoring related Obstetrics related Surgery related Treatment related Miscellaneous The NPDB classifies RNs into five categories: nonspecialized RNs, nurse anesthetists, nurse midwives, nurse practitioners, and clinical nurse specialists/advanced practice nurses. Nonspecialized RNs were responsible for the most malpractice payments (3,131 or 62.7%), followed by nurse anesthetists (1,035 or 20.7%), nurse midwives (459 or 9.2%), nurse practitioners (368 or 7.3%) and clinical nurse specialists/advanced practice nurses (8 or 0.2%). The majority of payments for malpractice claims were based upon monitoring, treatment, and medications problems, as well as obstetrics and surgery-related problems (NPDB, 2004). Today’s health care environment poses even greater liability risks for nurses. Liability risks that have contributed to the increased number of malpractice cases against nurses include: improper supervision/delegation, early patient discharge, nursing shortage, hospital downsizing, increased autonomy, advanced technology, and better-informed consumers (Croke, 2003). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines negligence as a “failure to use such care as a reasonably prudent and careful person would use under similar circumstances” and malpractice as: improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is a cause of action for which damages are allowed (JCAHO, 2005). 4. 5. 6. 7. 8. 9. 10. 11. Nursing Malpractice: Determining Liability Elements for Negligent Acts Eileen M. Croke, EdD MSN RN ANP LNCC Nurses must be concerned about malpractice litigation because nurses may now be held accountable for their own negligence. It is important for each nurse to know relevant law and legal doctrines, and incorporate them into everyday practice as a safeguard for the health care provider as well as the health care recipient (Guido, 2006). This article will review each element involved in determining legal liability for negligent acts. When reviewing a nursing malpractice case for merit, the legal nurse consultant (LNC) needs to determine if all liability elements are present. Two case analyses of nursing malpractice are presented as examples for determining nursing liability. This article is not intended to be a substitute for contacting an attorney when questions arise about nursing malpractice litigation. KEY WORDS Damages, Duty, Pecuniary Losses, Proximate Causation, Res ipsa loquitor • Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 In 2004, the median and mean payments for all types of registered nurses were $100,000 and $302, 737, respectively (NPDB, 2004). Nurses must be concerned about malpractice litigation because nurses may now be held accountable for their own negligence. It is important for each nurse to know relevant law and legal doctrines and incorporate them into everyday practice as a safeguard for the health care provider, as well as the health care recipient (Guido, 2006). Liability Elements of Malpractice Litigation For a nurse to become liable in a malpractice action, the law requires that certain elements be proven by the plaintiff before a successful case can be brought against the defendant nurse (Guido, 2006). The elements include duty, breach of duty, foreseeability, causation, injury, and damages, except as noted under doctrine res ipsa loquitor . When reviewing a nursing malpractice case for merit, the legal nurse consultant (LNC) needs to determine if all liability elements are present. If any of these elements is missing, the nurse is not liable for malpractice. The LNC must know relevant state laws and definitions applicable for each element of liability. A summary of medical malpractice laws indexed by state is located at www.mcandl.com/states.html . Duty. The duty of care that is owed to a patient is when an individual engages in an activity where that individual is under a legal duty to act as a reasonable and prudent person would act (Guido, 2006). Two aspects are involved in the duty of care. The first aspect that must be shown is that a duty was owed to the patient. This aspect is created by a legal nurse-patient relationship, not just by employment status; a legal nurse-patient relationship must exist before a lawsuit can commence. Examples of such a relationship include instances when the nurse accepts a patient care assignment, receives a report on a patient, or gives telephone advice to a patient. The LNC may be asked by the attorney to research the nature of the relationship between the plaintiff and alleged defendant nurse (Iyer, 2003). The second aspect of duty that must be proven is the scope of care that was owed to the patient. The standard of care owed to the patient is that exercised by a reasonable and prudent nurse with like training and experience and under the same or similar circumstances. Nurses are held accountable to the standard of care that was in existence at the time the care was rendered. Various sources for standards of care include JCAHO, State Nurse Practice Act (NPA), National League for Nursing (NLN), American Nurses Association (ANA), nursing specialty organizations, institutional policies and procedures (P&P), hospital nursing job descriptions, nursing journals and textbooks, and expert witness testimony. Breach of Duty. This occurs when a nurse’s care falls below the acceptable standard of care owed to the patient. The deviation can occur by an act of omission or commission. For example, a nurse omits giving an ordered insulin dosage to a known diabetic patient, and the patient lapses into a diabetic coma. Or a nurse gives an ordered insulin dosage to a known diabetic patient, fails to monitor his subsequent lack of oral intake, and the patient suffers a debilitating hypoglycemic reaction. Whether a nurse has satisfied or breached the duties of care owed to the patient is determined by the applicable standard of care. Due to the fact that medical and nursing knowledge is “more technical than the scope of common knowledge,” most state laws require the use of expert witness testimony for establishing the standard of care at issue in a medical or nursing malpractice lawsuit (Iyer, 2003). The expert witness must be qualified by reason of education, training, or experience to opine about a given subject matter (Testimony by Experts, 2000). If the negligence action falls within the common knowledge exception, such as when the subject matter is within the ordinary, common knowledge and experience of the layperson, expert testimony may not be required. Together, the attorney and LNC must determine the applicable standard of care owed to the patient in existence at the time the nurse rendered the patient care. The LNC reviews the entire medical record, “comparing and contrasting care with published standards determining whether or not there was a breach in the standard of care in a given subject matter” (Iyer, 2003, p. 262). The review also facilitates determining case issues and selection of qualified experts. Foreseeability. In this area, the nurse has a responsibility to foresee harm and take actions to eliminate the risk. The nurse does not need to foresee events that are “merely possible,” but only those that are “reasonably foreseeable” (O’Keefe, 2001). Could the nurse in the preceding example reasonably foresee that not monitoring a patient’s lack of oral intake subsequent to receiving insulin would result in a hypoglycemic reaction? “The challenge is to show that one could reasonably foresee a certain result based on the facts as they existed at the time of the occurrence rather than what could be said based on retrospective thinking and results” (Guido, 2006, p. 75). Causation (proximate cause). This area is more difficult for the plaintiff attorney to prove. Causation builds upon cause-in-fact and foreseeability. In cause-in-fact (also known as the “but-for” test), the plaintiff must show that the nurse’s breach in the standard of care actually resulted in the plaintiff’s injury and that these injuries were reasonably foreseeable. For example, a nurse may administer a wrong drug dosage to a patient in breach of standard of care, but there was no subsequent injury; therefore, the plaintiff does not have a cause of action. When determining a nurse’s negligent action in relation to the alleged injury, Iyer (2003) recommends that the LNC should ask the following questions: Did the negligence cause the injury? Did the breach cause all or part of the plaintiff injury? Is there any reason why the result would have been the same absent the deviation? Legal definitions for causation are found in jury instruction guides for the jurisdiction in question. “The jury instruction guide states the precise language that a judge will 1. 2. 3. Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 • read to the jury when instructing them about the information to consider when rendering a verdict. The information that the jury will be asked to consider is what the attorney will have to prove in court” (Iyer, 2003, p. 282). State-by-state jury instructions can be located online at www.llrx.com/ columns/reference38.htm . Injury. In malpractice litigation, the plaintiff must prove that the injury claimed was directly related to the negligent act of the professional defendant. Categories of injuries are physical, financial, or emotional, with the later two usually accompanying physical injury. Together, the attorney and LNC must distinguish a “proximately caused injury” from the injury that the plaintiff would or did suffer irrespective of any breach (Iyer, 2003). The LNC reviews, interviews, researches, summarizes, and evaluates all medical documentation relevant to the alleged injury. Damages. Monetary awards are given to compensate the plaintiff for the injury proximately caused by the negligent action of the defendant. Categories of damages include: General Damages: monetary compensation for a loss that cannot be measured in “nominal amounts.” Types of losses may include disfigurement, disability, and past, present, and future pain and suffering. Special Damages: monetary compensation for losses due to injury. Types of losses may include medical expenses, lost income, and past, present, and future losses due to injury. (General and Special Damages may be grouped together into one category called Compensatory Damages). Emotional Damages: monetary compensation for anxiety or emotional distress associated with injury. Punitive Damages: monetary compensation for intentional or grossly negligent misconduct. Punitive damages are awarded to “punish” the individual and to deter similar future actions. Two classification awards for damages are economic and non-economic. Economic damages concern pecuniary losses, such as medical expenses or lost wages, and non-economic damages concern non-pecuniary losses, including pain and suffering, and loss of consortium. State laws vary on awarding damages, with some capping the award amounts. For example, in 1975, California wrote into law the Malpractice Injury and Compensation Reform Act (MICRA), limiting non-economic damages in medical malpractice cases to $250,000. Additionally, 24 states have enacted laws limiting caps on non-economic damages. When an LNC or life care planner is involved in assisting the attorney with calculating economic damages, having knowledge of relevant state laws is a necessity. Doctrine Res Ipsa Loquitor : “The thing stands for itself.” Under this doctrine, the plaintiff does not need to prove how the injury occurred or who was responsible. The basic premise is that, without negligence, the injury would not have happened. In most states, the plaintiff does not need the testimony of an expert witness. For the doctrine to apply, the plaintiff must prove the following three elements (Guido, 2006, p. 86): The accident must be the kind that ordinarily does not occur in the absence of someone’s negligence; 1. 2. 3. 4. 1. The accident must be caused by an agency or instrumentality within exclusive control of the defendant; and The accident must not have been due to any voluntary action or contribution on the part of the plaintiff. The following two case analyses of nursing malpractice are examples for determining nursing liability. They are not intended to be a substitute for contacting an attorney when questions arise about nursing malpractice litigation. # Case Analysis Lunsford v. Board of Nurse Examiners, 648 S.W.2d 391; 1983 Tex. App. LEXIS 4087 Case Scenario: A patient, Donald Floyd, was brought by a friend, Miss Farrell, to Willacy County Hospital with complaints of chest pain accompanied by numbness and pain radiating down his left arm. Miss Farrell left Mr. Floyd in the hospital waiting room and went in search of medical assistance for Mr. Floyd. Within the facility, Miss Farrell spoke with a physician who subsequently referred her to seek help from the registered nurse on duty, Nurse Lunsford. Nurse Lunsford was ordered by the physician to send the patient and his companion to Valley Baptist Hospital, 24 miles away. The hospital had a policy to send all patients to Valley Baptist Hospital unless the patient had a physician on the hospital’s staff or unless it was a “life-death situation.” Upon entering the waiting room, Nurse Lunsford found Mr. Floyd lying on a table complaining of chest pain that also had radiated to his arms. After questioning Mr. Floyd, Nurse Lunsford learned that he had not undertaken any strenuous exercise or eaten anything unusual that day that may have influenced the onset of his symptoms. Despite suspecting “cardiac involvement,” Nurse Lunsford did not take Mr. Floyd’s vital signs. Nurse Lunsford gave the following instructions to Miss Farrell: take Mr. Floyd to Valley Baptist Hospital; speed there; drive with the automobile’s emergency flashers on; and use the automobile’s citizens’ band radio to call for help on the way to Valley Baptist Hospital. Nurse Lunsford also asked Miss Farrell about her knowledge of cardiopulmonary resuscitation (CPR), as there might be a chance that she may need to use it during transport. Mr. Floyd died five miles from Willacy Hospital on the way to Valley Baptist Hospital. The Texas Board of Nurse Examiners (1983) conducted a hearing on the actions of Nurse Lunsford relating to Mr. Floyd death. The Board, citing Texas Rules of Evidence 4525 (B) (9), found that Nurse Lunsford’s conduct had been “unprofessional and dishonorable… likely to injure patients or the public” and suspended Nurse Lunsford’s Texas RN license for one year. The District Court of Travis County, 200th Judicial District affirmed the Board’s decision. Nurse Lunsford appealed, citing she did not owe a duty to Mr. Floyd because a nurse-patient relationship had not been established between the parties. The Court of Appeals of Texas, Third District, Austin affirmed the judgment of the District Court. Elements of Liability: Duty. Nurse Lunsford cited she did not have a nurse- patient relationship with Mr. Floyd, as he had not been 2. 3. • 6 • Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 admitted to the hospital and was not a patient of the staff physician. The Courts found that Nurse Lunsford automatically owed a duty to Mr. Floyd through the receipt of her Texas Registered Nurse licensure and that a nurse-patient relationship existed when she met Mr. Floyd in the hospital waiting room in need of life- threatening emergency care. Texas Board of Nurse Examiners Rule 22 T.A.C 217.11(1)(M),(3)(A)(i) requires an RN to assess the health status of each patient and institute appropriate nursing actions that might be required to stabilize the patient’s condition and/or prevent further complications. Breach of Duty. The Board found and Courts affirmed that Nurse Lunsford failed to assess and implement appropriate nursing actions. Specifically, the following breaches in the standards of care were cited: Failure to assess Mr. Floyd’s medical status; Failure to inform the physician of Mr. Floyd’s cardiac condition and potential life-death medical status; and Failure to institute appropriate nursing actions, such as taking vital signs and placing the patient on electrocardiogram (ECG) machine, to stabilize Mr. Floyd’s medical condition and prevent further complications and, ultimately, his demise. Foreseeability. Nurse Lunsford should have been able to reasonably foresee the potential complications related to Mr. Floyd’s complaints, especially since she admitted to have suspected “cardiac involvement.” Nurse Lunsford also questioned Miss Farrell about her knowledge of CPR, which demonstrates Nurse Lunsford’s forseseeability of a cardiopulmonary arrest. Causation. Nurse Lunsford’s breach in the standards of care proximately caused the injury. If she had assessed the patient, communicated to the physician about the patient’s life-threatening condition, and implemented nursing interventions, his death could have been prevented. Injury. Nurse Lunsford’s breach of duty and failures to assess the patient’s condition, to communicate his condition to the physician, and to implement nursing interventions to help stabilize his condition resulted in the cardiac event that lead to his death. Damages. Nurse Lunsford’s RN license was suspended for 1 year. #2 Case Analysis Muskopf v. Maron, 764 N.Y.S.2d 741; 2003 N.Y. App. LEXIS 10050 Case Scenario: Susan Muskopf, a patient of Dr. Barry Maron, was admitted to Wyoming County Community Hospital for a unilateral hand repair due to carpal tunnel syndrome. At the time of admission, Ms. Muskopf had been diagnosed with bilateral carpal tunnel syndrome, although her left hand was asymptomatic at the time of surgery. Prior to the surgery, Ms. Muskopf questioned the hospital nurse about the location of the surgical procedure, stating that she thought the surgery was to be performed on her right • 1. 2. 3. • • • • hand. Subsequently, the hospital nurse reviewed all the pre- operative medical documents in the patient’s chart, including the physician’s records and informed consent form signed by the patient, and all the documents indicated that the surgery was to be performed on the patient’s left hand. The hospital nurse did not notify the physician of the patient’s concern regarding the site of the surgery and did not document this conversation in the patient’s medical record. The patient brought a medical malpractice action suit against Dr. Maron, the Wyoming County Community Hospital, and the County of Wyoming, seeking damages for injuries she allegedly sustained when the physician operated on her left hand instead of her right hand. The patient also brought an independent negligence cause of action collectively against the hospital and the county for the failure of the hospital nurse to prevent the surgical error despite having been informed by the patient that she thought the surgery was to be done on her right hand. The Supreme Court, Wyoming County, granted a cross motion of the Wyoming County Community Hospital and County of Wyoming defendants for summary judgment, dismissing the complaint against them (765 N.Y.S.2d 537; 2003 N.Y. App. LEXIS 10047). On appeal to the Supreme Court of New York, the plaintiff contended that the Supreme Court, Wyoming County, erred in granting the defendants’ cross motion for summary judgment. The defendants maintained the contention that they were shielded from tort liability, based on the fact that the hospital nurse had reviewed and followed the physician’s pre-operative orders. On review by the State Supreme Court of New York, it was cited that the defendants had met their initial burden of proof, based, in part, upon affidavit testimony provided by a nurse expert witness, who opined that the nursing care rendered by the hospital nurse met the standard of care: once the hospital nurse was questioned by the patient concerning the surgical site, the hospital nurse reviewed all the preoperative physician records, as well as the informed consent form signed by the patient, and all the records indicated the surgery was to be performed on the patient’s left hand. An issue of fact was raised by the plaintiff through affidavit testimony provided by the physician expert witness, who opined that the hospital had breached “the accepted standards of medical practice by failing to undertake a comprehensive review of the plaintiff’s case, including a specific inquiry to the attending physician and documentation of the results of that inquiry, when the hospital nurse learned of plaintiff’s doubts concerning the site of the surgery” (Muskopf v. Maron, 2003, p. 2). The plaintiff’s physician expert’s opinion was based, in part, on the hospital nurse’s own deposition testimony: “If a patient had a question concerning the side on which surgery was to be performed, she [the nurse] would document that she [the nurse] had called the doctor and that he would be in to speak to the patient” (Muskopf v. Maron, 2003, p. 2). The Supreme Court of New York found the issue of fact undisputable, in that the hospital nurse did not follow through with notifying the physician of the patient’s concern Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 • 7 and denied the defense’s motion that they were shielded from tort liability. The judgment was reversed on the law with costs, the cross motion was denied, and the complaint against the Wyoming County Community Hospital and County of Wyoming defendants was reinstated. Elements of Liability: Duty. A legal nurse-patient relationship existed between the patient and the hospital nurse. The hospital nurse owed a duty to the patient to ensure that the physician was notified of the patient’s concern regarding the surgical site. In the hospital nurse’s own deposition testimony, she stated, “If a patient had a question concerning the side on which the surgery was to be performed, she [the nurse] would document that she [the nurse] had called the doctor and that he would be in to speak to the patient” (Muskopf v. Maron, 2003, p. 2). Breach of Duty. The hospital nurse breached the standard of care with an act of omission by not informing the physician of the patient’s concern regarding the surgical site. Forseeability. The hospital nurse should have been able to reasonably foresee the potential complication of wrong site surgery related to not informing the physician of the patient’s stated concern. Causation. The hospital nurse’s breach in the standard of care proximately caused the injury. If the hospital nurse had • • • • notified the physician of the patient’s concern about the surgical site, the surgical error could have been prevented. Injury. The patient had surgery on the wrong hand. The left hand was asymptomatic at the time of surgery. Damages. For the appellants, the Supreme Court of New York unanimously reversed the appealed judgment on the law with costs, the defense’s cross motion for summary judgment was denied, and the complaint against the Wyoming County Community Hospital and County of Wyoming defendants was reinstated. Summary When evaluating a nursing malpractice case for merit, the LNC must evaluate each liability element for possible negligence. The first element that must be determined is the existence of a legal nurse-patient relationship between the parties and based upon the relationship what was the scope of care owed to the patient by the nurse [defendant]. The LNC must then determine whether or not there was a breach in the standard of care, identify proximate causation and injury. Once the evaluation is complete, the LNC must be able to provide the attorney with a precise report (verbal or written) based upon each liability element. • • continued on page 24 2 • Journal of Legal Nurse Consulting • Summer 2006 • Volume 17, Number 3 are examined. Although these areas are not as frequently cited in medical litigation as some other clinical areas, for an LNC dealing with such, these chapters are a wonderful resource for those individuals with minimal baseline knowledge. In addition, this section has two chapters that address topics often entangled in the litigation process: the office based medical record and the independent medical examination (IME). The IME chapter delineates the step-by-step process of an IME, culminating with final impressions and professional opinions regarding the IME. The section on office based medical records was very helpful. As many LNCs are aware, office based verbal communication may not be adequately corroborated with written documentation – and may even serve as the wavering domino leading to an unfortunate cascade of events resulting in medical malpractice litigation. Part III, chapters 21 through 38, deal specifically with clinical specialty areas. This is the “meat and potatoes” for LNCs who are routinely involved in medical malpractice litigation. These chapters address many high-volume, high-risk areas of clinical practice, e.g. critical care, emergency department, intravenous therapy, obstetrics, orthopedics, pediatrics, skin trauma, medication administration, and psychiatric care. The reader will benefit tremendously from the expertise and experience of each contributing author. If an LNC is already clinically experienced in one of these particular fields, it is likely that the information contained within the chapter will reinforce an existing knowledge base. For the LNC without clinical expertise in one or a number of these designated clinical areas, the chapters will provide an excellent starting point to explore pertinent definitions, patient care interventions, treatment complications, and practice standards. Part IV of the text explores forensic aspects of care. Although any LNC may encounter altered medical records or utilize a forensic document examiner, for those involved in criminal prosecutions, chapter 41 will be highly beneficial. A detailed discussion of forensic evidence from sexual assaults, gunshot wounds, auto accidents, and poisonings provide examples. The final chapter of the book addresses autopsy reports, which may be an integral component of malpractice, product liability, or toxic tort litigation. The book concludes with an appendix of medical terminology, Internet resources, textbook references, and a glossary. These four subcomponents, as evaluated separately from the main text, are excellent as a stand-alone reference for the practicing legal nurse consultant. In summary, authors Iyer, Levin, and Shea have provided the legal and nursing community a comprehensive and worthwhile resource for medical record examination. Whatever your level of competence in legal nurse consulting practice, whether novice or seasoned expert, this publication will be as valuable addition to your reference library. Beth C. Diehl-Svrjcek , MS RN CCRN NNP CCM LNCC, is a Neonatal Nurse Practitioner at Johns Hopkins Hospital in Baltimore, Maryland, where she functions as a Transport Nurse for the Maryland Regional Neonatal Transport Program. She has more than 27 years of combined experience in adult critical care, neonatal intensive care, pediatrics, post acute pediatrics, case management, nursing staff development, utilization review, and nursing supervision. She maintains an independent LNC practice specializing in medical malpractice for plaintiff and defense litigation. She has been used as an Expert Witness since 1988. A former board member of the Greater Baltimore Area Chapter of AALNC, she maintains certifications as a critical care nurse, case manager, and legal nurse consultant. She can be reached at [email protected] . References Croke, E. (2003). Nurses, negligence and malpractice. American Journal of Nursing, 103 (9), 54-63. Guido, G. (2006). Legal and ethical issues in nursing (4th ed.). Upper Saddle River, N.J.: Prentice Hall Publishers.Iyer, P. (Ed.). (2003). Legal nurse consulting principles and practice (2nd ed.). Baton Rouge, LA: CRC Press.Joint Commission on Accreditation of Health care Organizations (2005). Sentinel Events Glossary of Terms. 2005. Retrieved December 30, 2005, from www.jcaho.org/accredited+organizations/sentinel+event/glossary.htmLunsford v. Board of Nurse Examiners, 648 S.W.2d 391; 1983 Tex. App. LEXIS 4087. Retrieved January 9, 2006, from http://lexisnexis.comMuskopf v. Maron, 765 N.Y.S.2d 537; 2003 N.Y. App. LEXIS 10047. Retrieved March 1, 2006, from http://lexisnexis.comMuskopf v. Maron, 764 N.Y.S.2d 741; 2003 N.Y. App. LEXIS 10050. Retrieved March 2, 2006, from http://lexisnexis.com National Practitioner Data Bank 2004 Annual Report. Retrieved December 30, 2005, from www.nphd-hipdb.com/pubs/fs/fact%20Sheet%20-%20National%20Practitioner%20Data%20Bank.pdfO’Keefe, M. (2001). Nursing practice and the law: Avoiding malpractice and other legal risks. Philadelphia: F. A. Davis. Testimony by Experts, Federal Rule of Evidence 702 (2000). Nursing Malpractice: Determining Liability Elements for Negligent Acts continued from page 9 Eileen M. Croke , EdD MSN RN ANP LNCC, is an Associate Professor of Nursing at California State University Long Beach, CA, where she teaches the nursing course “Legal Issues in Health Care.” She has been an LNC since 1989, specializing in medical malpractice and personal injury, plaintiff, and defense litigation. She serves as an expert witness for the California Board of Registered Nursing. She can be reached at [email protected] .