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Ethical, Legal, and Quality Considerations in Critical Care Nursing

Oct 03, 202416 min read

Also read: PALMER Reviewer

The word Ethics is derived from ethos (character, Greek) and mores (customs, Latin). It is a branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct, often addressing disputes of moral diversity.

There are four foundations for ethical decision making:

  1. Professional Codes and Standards e.g. the Philippine Nurse’s Act (R.A. 9173), the Nuremberg Code, etc.
  2. Institutional Policies
  3. Legal Standards e.g. the Patient’s Bill of Rights, the Nursing Code of Ethics

Ethical Principles

  1. Beneficence: “doing good”; actively acting for the best interest of the patient.
    • Example: child immunization that causes discomfort during administration, but creates protection from disease for both the individual and society.
  2. Non-maleficence: “avoiding evil”; acting to protect the patient against harm.
  3. Autonomy: allowing the patient to exercise self-determination and freedom from duress; protection of their independence and freedom.
    • Example: the preoperative consent assured in writing.
  4. Privacy: the right of the patient to be free from unjustified access by others.
  5. Confidentiality: the protection of information, limited only to the healthcare team directly involved in patient care and those given authorization.
  6. Fidelity: “promise-keeping”; the act of fulfilling all preordained and uptaken roles and responsibilities by the nurse.
    • Example: after assessment for pain and offering a plan to manage it, this principle encourages the nurse to do their best in keeping to the plan and improving patient comfort.
  7. Veracity: truthfulness and honesty, so long as the information will not result in harm to the patient.
  8. Justice: the principle of fairness. It implies equal treatment for all clients, and the distribution of resources to those who require them the most (social justice).

Contemporary Issues in Critical Care Nursing

  1. Informed Consent: a legal contract indicating the well-informed and voluntary consent of an individual to undergo a procedure. It serves to protect the client against unauthorized procedures, and to protect the healthcare workers against legal action.
    • Explanation of procedures should include benefits, risks, alternatives, complete information and explanation for the procedure, where the patient is given ample opportunity to express concerns and inquiries.
    • No duress of any form should be placed upon the patient during the process of obtaining informed consent.
    • Patients must make decisions based on knowledge and understanding of accurate and appropriate information voluntarily.
    • To be able to give consent, individuals must be both physically (18+) and mentally (Unaltered LOC, sane) matured.
    • Right to Withdraw Consent may be exercised.
    • Substitutes or Proxy Consent may be provided when the individual is not qualified to provide consent. These may be signed by parents, relatives, legal guardians, and the next of kin.
    • In emergency situations where the individual is not able to provide consent and no relatives are available, the healthcare provider decides on behalf of the patient in the best interests of preserving life.
    • Right to Refuse is always respected.
      • If refused, and there are no risks: respect the decision.
      • If refused, and there are risks: explain the risk to patients or relatives.
      • If the patient still refuses life-saving treatment or devices, sign a Waiver.
  2. Determining Capacity reflects a medical decision on patient’s ability to participate in the decision-making process of their healthcare.
  3. Advance Directives: statements the patient wishes to be respected when their decision-making becomes impaired. This includes Treatment Directives or “Living Wills”, which is a legal document that specifies treatment choices and interventions desired in advance; and Proxy Directives, which produces a durable power of attorney for the patient’s health care.
  4. End-of-Life Care Issues: end-of-life care is physical, emotional, social, and spiritual support for patients and their families. Its primary goal is to control pain and other symptoms to make the patient as comfortable as possible i.e. improve quality of life. Some issues include:
    • Decisions to forego life-sustaining treatments.
    • Nutrition and hydration
    • Pain management
    • Resuscitation decisions: Do Not Resuscitate (DNR) orders and Do Not Intubate (DNI) orders.
  5. Paternalism: violation of the patient’s autonomy by deciding on their behalf “for their good.” Health care professionals believe they know what is best for the patient.

Laws in Critical Care Nursing

  1. Scope of Nursing Practice based on R.A. 9173, the Philippines Nursing Act of 2002

    Scope of Nursing Practice

    The scope of nursing practice is defined under Section 28, Article VI of the Philippine Nursing Act of 2002. A person is said to practice nursing when they render nursing services to other individuals or groups from womb to tomb. Nursing services include but are not limited to:

    • (1) provision of care through the nursing process
    • (2) collaborate with communal resources and health teams
    • (3) provide health education
    • (4) take student nurses as apprentices, and
    • (5) undertake nursing and health human resource development, training, and research.
    Link to original
  2. Nurse’s Code of Ethics: Professional Regulation Commission, 2004
  3. Patients’ Bill of Rights and Obligations: Senate Office of the Secretary, 2016
  4. Dying Patients’ Bill of Rights: American Journal of Nursing, 1975
  5. Senate Bill 586: Senate Office of the Secretary, 2010. An act providing palliative and end-of-life care, appropriating funds therefor and for other purposes

Patient’s Bill of Rights

  1. Right to Appropriate Medical Care and Humane Treatment
  2. Right to Informed Consent
  3. Right to Privacy and Confidentiality
  4. Right to Information
  5. Right to Choose Health Care Provider and Facility
  6. Right to Self-Determination
  7. Right to Religious Belief
  8. Right to Medical Records
  9. Right to Leave
  10. Right to Correspondence and Visitors
  11. Right to Express Grievances
  12. Right to be Informed of His Rights and Obligations as a Patient

The Philippine Nursing Act of 2002

R.A. 9173, which seeks to better protect and improve the nursing profession, but still upholding the same revered state policies and aspirations. It outlines the state responsibility, pertaining to the government’s responsibility to protect and improve the nursing profession through the institution of measures for the attainment of:

  • Relevant nursing education
  • Humane working conditions
  • Better career prospects
  • Dignified existence of the Filipino nurse

Continued Professional Development/Education

R.A. 10912, The Continuing Professional Development (CPD) Act of 2017 for nursing mandates 15 credit units for professional license renewal, in this case every 3 years. These are obtained from formal learning, non-formal learning, informal learning, self-directed learning, online learning activities, and professional work experience.

The state guarantee is the government’s commitment to deliver quality health care services by providing adequate nursing personnel throughout the country (Sec. 2, Art. II, R.A. No. 9173).

The act outlines the scope of nursing practice and prohibitions, which can result in the revocation and suspension of registration (not longer than four years) and administrative, civil, and criminal liabilities.

  1. Unprofessional and unethical conduct
  2. Gross incompetence or serious ignorance
  3. Malpractice or negligence in the practice of nursing
  4. Use of fraud, deceit, or false statements in acquiring registration, licensure, or temporary special permit.
  5. Violation of the act and rules, regulations, code of ethics, and policies.
  6. Practice during suspension

Those taking the board exam must be:

  1. At least 18 years old
  2. Satisfactorily graduated from a Bachelor’s Degree in Nursing from a CHED Accredited University/College.

Inactive Nurses

Inactive nurses have to undergo one month of didactic training and three months of practicum before returning to practice. Inactivity is defined as the cessation of professional activity for five consecutive years.

Process of Ethical Analysis

According to the American Association of Critical Care Nurses

  1. Assessment: (1) identify the problem: clarify competing ethical claims, conflicting obligations, and personal and professional values; (2) gather data: distinguish morally relevant facts (medical, nursing, legal, social, psychological, religious, philosophical) and beliefs/values; (3) identify individuals involved in the problem’s development and who should be involved in decision-making.
  2. Planning: consider all options and plans. Be creative. Look into institutional policies and/or procedures that address the issue. Identify pros and cons for the approaches identified. Analyze if the plan follows ethical theories and principles.
  3. Implementation: choose a plan and carry it out.
  4. Evaluation: outline the results, identify harm or good consequences, and identify necessary adjustments in institutional policies or other strategies to avoid similar issues in the future.

Quality & Safety in Critical Care

Knowledge Translation

The application of research in nursing practice. It involves an effective and timely synthesis, exchange, and application of knowledge among researchers and users to capture the benefits of research.

Evidence-Based Nursing

As a subdomain of evidence-based practice, this is the application of the best available evidence, often from research findings, into the clinical setting to ensure best practice.

In a definition synthesized by Scott and McSherry, evidence-based nursing is:

an ongoing process by which evidence, nursing theory, and the practitioners’ clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the indiviudal.

Evidence-Based Nursing undergoes various steps:

  1. Ask Clinical Questions via the PICOT format or the SPIDER tool.
    • PICOT: used to frame a clinical question
      • Population: characteristics, conditions, problems of the population
      • Intervention: what are the intervention, assessment, screening, treatment, or service delivery model being considered? What is the proposed intervention?
      • Comparison: what is the main alternative to the intervention, assessment, or screening approach?
      • Outcome: what do you want to accomplish, measure, or improve?
      • Time frame: how long will it take to reach the desired outcome?
    • SPIDER: a tool used when dealing with experiences rather than scientifically measurable data. It focuses more on the design rather than the intervention. These deal with samples rather than a patient or populations. It tends to be used for questions that begin with “What are the experiences of…?”
      • Sample: the group of participants
      • Phenomenon of Interest: what behaviors and experiences are being considered?
      • Design: how was the study devised and conducted?
      • Evaluation: the measurement of the outcome. This may not be strictly empirical.
      • Research Type: the method (qualitative, quantitative, mixed).
  2. Gather Evidence
    • Internal Evidence: obtained directly from clients or institutions
    • External Evidence: obtained from scientific literatures, research databases, and the like. This utilizes meta-analysis.
  3. Assess the Evidence: once articles are selected for review, rapid appraisal is done to determine the most relevant, valid, reliable, and applicable evidence for the clinical question.
    • Ask “are the results of the study valid?”, “What are the results and are they important?”, “Will the results help me care for my patients?”
    • Internal Evidence: does the study investigate a population similar to my client/s?
    • External Evidence: do my client/s respond to the intervention?
  4. Make Clinical Decisions: synthesize the studies to determine if they produce similar conclusions, thus supporting EBP decisions or change. Evidence alone is not sufficient to justify a change in practice. Clinical expertise, based on patient assessments, laboratory data, data from outcomes of management programs, as well as patients’ preferences and values are important components of EBP.
    • Define your clinical question.
    • Extrapolate any applicable information from external evidence.
    • Consider clinical expertise.
    • Incorporate the needs and perspectives of clients.
    • Develop assessment and treatment plans.
  5. Evaluate the clinical decision and its impacts. Its results should be disseminated. This reduces needless duplication of effort and promotes evidence-based clinical approaches. Successful initiatives for dissemination includes presentations at local, regional, and national conferences; reports in peer-reviewed journals; professional newsletters; and publications for general audiences.

Quality & Safety Monitoring

  1. Care Bundles: a “bundle” is a group of 3 to 5 evidence-based interventions that, when performed together, have a better outcome that if performed individually. These can be used to ensure the delivery of the minimum standards of care. An example of this is the Sepsis Care Bundle, part of the International Surviving Sepsis campaign. It is the most widely utilized bundle.
    • These may be used as an audit tool to assess the delivery of interventions (though, not individually).
    • These encourage the review of evidence and modification of clinical care guidelines, engendering staff education in best practice.
    • Its key principle is the high level of adherence to all components.
  2. Checklists
  3. Continuous Quality Improvement (CQI)
  4. Plan-Do-Check-Act (PDCA) Cycle, also known as the Deming Cycle or Shewhart Cycle, is a management tool for continuous improvement of a business’s products or processes. It can be applied to standardize nursing management and thus improve the nursing quality and increase the survival rate of patients. Simply put, it is used to implement change, solve problems, and continuously improve nursing management processes. It provides continuous improvement because it is a cyclical process. The use of this model does not require much expertise and can be done with little to no training.
    • Plan the change or improvement to be made.
    • Do: perform a pilot test of the change.
    • Check: gather data about the change, ensuring it is successful.
    • Act: implement the change on a broader scale; continuing “Checking” and repeating the cycle as necessary.
    • Advantages: all appropriate steps are followed, improvement is systematized, provides an effective process improvement guide, informs future improvement by providing feedback, and maintains order during problem-solving.
    • Disadvantage: requires significant commitment over time

Multidisciplinary Plans of Care

A multidisciplinary plan of care is a set of expectations for the major components of care a patient should receive during the hospitalization to manage a specific medical or surgical problem. It provides an interdisciplinary, comprehensive blueprint for patient care. The result is a diagnosis-specific plan of care that focuses the entire care team on expected patient outcomes.

This methodology benefits both the patients and the hospital system:

  • Improves patient outcomes (e.g., survival rates, morbidity, quality of life)
  • Increased quality and continuity of care
  • Improved communication and collaboration
  • Identification of hospital system problems
  • Coordination of necessary services and reduced duplication
  • Prioritization of activities
  • Reduced length of stay and health-care costs

A multidisciplinary plan of care is developed by a team of individuals who closely interact with a specific patient population. This commonly includes physicians, nurses, respiratory therapists, physical therapists, social workers, and dietitians. Formats for multidisciplinary plans of care include:

  • Discharge planning
  • Discharge outcomes
  • Patient goals
  • Assessment and evaluation
  • Consultations
  • Tests
  • Medications
  • Nutrition
  • Activity
  • Education

Each of these may be divided into daily activities, or grouped into phases of hospitalization (pre-, -intra-, and postoperative phases). This plan of care optimizes communication, collaboration, coordination, and commitment to the pathway process.

Information and Communication Technologies in the CCU

  1. Clinical Information System
  2. Computerized Provider Order Entry (CPOE)
  3. Hand-held Technologies
  4. Telehealth Initiatives (Tele-ICU)

Social Care Services

  1. PhilHealth
  2. Department of Health (DOH)
  3. Department of Social Welfare and Development (DSWD)
  4. Philippine Amusement and Gaming Corporation (PAGCOR) aids in funding state-run hospitals and programs.
  5. Philippine Charity Sweepstakes Office is the principal government agency for raising funds for health programs, medical assistance and services, and charities of national character.

Evidence-Based Practice (EBP)

The integration of clinical expertise, patient values, and the best research evidence available into the decision-making process for patient care (Sackett, 1996). It is a problem-solving approach to decision-making the integrates the best available scientific evidence with the best available experiential evidence (from both patient and practitioner), and encourages critical thinking in the judicious application of evidence to the care of the individual patient, patient population, or system.

  • EBP transitions practice from tradition to sound scientific evidence. Nurses are provided a process by which questions can be answered. It improves patient outcomes by making sure care is aligned with the current best practices.

EBP provides many advantages and disadvantages. It is also hindered by multiple barriers.

  • Provides better information to practitioner, enabling consistent and client-focused care for better patient outcomes through a structure process that increases decision-making confidence. It generalizes information that contribute to the science of nursing and provides guidelines for further research, helping nurses provide high-quality patient care. EBP can also tackle reducing costs, technological advancement, and lifelong learning.
  • Some protocols may not have enough evidence for EBP. The practice of EBP itself is very time-consuming and can be prone to publication bias. The use of EBP in care reduces client choice and professional judgement/autonomy (due to set interventions and systematized decision-making), and suppresses creativity. It also influences legal proceedings.
  • Barriers that prevent the efficient use of EBP can be due to a lack of value for research in practice, administrative support, knowledgeable mentors, time in researching, knowledge about researching, and available research. Bringing change can be difficult in some systems, especially those with no experience or knowledge about EBP. Research reports themselves can be very complex, setting a high bar of entry for the use of EBP.

EBP Process

Evidence-based practice is an explicit process. It begins with a focused practice question, with which the best evidence is gathered. Evidence is critically appraised, synthesized, translated/contextualized into the setting for its use, and disseminated.

The implementation of EBP also follows a series of steps:

  1. Ask a clear question about patient issues and determine an ultimate goal.
  2. Acquire the best evidence with relevant clinical articles from legitimate sources.
  3. Appraise the resources to determine if the information is valid, and of optimal quality and relevance.
  4. Apply the evidence by making decisions based on nursing expertise and the new information.
  5. Assess outcomes to determine if the treatment was effective and should be considered for other patients.

Step 1, asking a clear question, can be aided with two tools (also discussed earlier in Evidence-Based Nursing).

  1. PICO: (no T this time) used to frame a clinical question
    • Population/Patient Problem or Characteristics: characteristics, conditions, problems of the population
    • Intervention: what are the intervention, assessment, screening, treatment, or service delivery model being considered? What is the proposed intervention?
    • Comparison: what is the main alternative to the intervention, assessment, or screening approach? This may be omitted when not necessary.
    • Outcome: what do you want to accomplish, measure, or improve?

PICO Examples

In a 30-year old male patient diagnosed with depression (P), is St. John’s Wort (I) as effective as SSRIs (C) for reducing depressive symptoms (O)?

In adults with back pain (P), does yoga therapy (I) reduce pain (O)?

  1. SPIDER: a tool used when dealing with experiences rather than scientifically measurable data. It focuses more on the design rather than the intervention. These deal with samples rather than a patient or populations. It tends to be used for questions that begin with “What are the experiences of…?”
    • Sample: the group of participants being studied
    • Phenomenon of Interest: what behaviors and experiences are being considered? What is the topic?
    • Design: how was the study devised and conducted?
    • Evaluation: the measurement of the outcome. This may not be strictly empirical.
    • Research Type: the method (qualitative, quantitative, mixed, phenomenology, ethnography, grounded theory, case study).

Clinical Practice Guidelines

Clinical Practice Guidelines are systematically developed statements (potentially through EBP) to assist the practitioner with decisions about appropriate health care for specific clinical circumstances. This aims to tackle recent concerns about variability in clinical practice, cost, quality, and legal liability. Guidelines can differ considerable in comprehensiveness, format, frequency of review, and ease of use. It follows its own set of development guidelines:

  1. Identify the topic
  2. Create a multidisciplinary, expert group
  3. Gather and assess evidence
  4. Create recommendations from evidence
  5. Allow outside reviewers to review the recommendations
  6. Update the guideline periodically

Guidelines should be appraised critically. In the first place, its validity should be scrutinized. Questions such as “Was a systematic review used?”, “Were all treatment options and outcomes considered?”, etc. are applied. A second set of critique is provided in applying the practice, asking “Is the burden of illness too low, or is the cost of implementation too high to warrant implementation of a guideline?”, and “Are patient beliefs compatible with the guidelines?”

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