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

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 StandardsProfessional Nursing practiceTopic 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

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Group 1 Group 2

Class 1 82 95

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


• Many nurses do not want theses rights of responsibilities preferring instead to focus on clinical tasks only.

• What is wrong with this?????


• 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?


Alternative care models

• Impact of day surgery. Less time to access patients

• Primary health care.


Advances in Technology

• The Internet

• Research : legal implications


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.


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 hearingLinda 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+Sophie+Heathcote&hl=en&sa=X&ei=3TxRUZ71KourrAevtYHACw&ved=0CCsQ6AEwAA#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?

EthicsTopic 03 Ethics1.Theories 2.Principles3.Resolving ethical dilemmas – models of decision making 4.Discontinuing treatment 5.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 EthicsValue statement 1• Nurses respect individual needs, values, culture and

vulnerability in the provision of nursing care

Code of EthicsValue statement 2• Nurses accept the rights of individuals to make informed

choices in relation to their care

Code of EthicsValue Statement 3• Nurses promote and uphold the provision of quality nursing

care for all people

Code of EthicsValue 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 EthicsValue Statement 5• Nurses fulfill the accountability and responsibility inherent in

their roles

Accountability and ResponsibilityAccountability: 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 EthicsValue Statement 6• Nurses value environmental ethics and a social, economic

and ecologically sustainable environment that promotes health and well being

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 ConductThe 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


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


• 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


• 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?


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


Case scenarios

• A law student left arm was amputated after 03 of applying POP plaster .

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Documents

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