Patient Advocacy — Simply Complicated

By Joan Spitrey via Multibriefs

For 15 straight years, the American public has rated nurses highest in regards to honesty and ethical standards. This trust is often easily gained, as nurses are the ones at the bedside while other healthcare providers come and go through the day.

The nurse is often the one who sees the needs of patients, and that caring does not go unnoticed. The nurse is the "translator" or go between for all the interdisciplinary teams — always being watchful of their patients' unique needs.

However, with much respect comes much responsibility — as a recent court case shows.

Most of the nurses' responsibilities are addressed by their state nurse practice act and acceptable standards of practice. As with most professions, nurses are also guided by a code of ethics that directs their professional decision.

The American Nurses Association's (ANA) Code of Ethics for Nurses sets out nine provisions for nurses to abide when caring for their patients. These provisions lay the foundation for care and are reminders for the nurse of their professional obligation. The provisions include the direction for nurses to practice with compassion and respect, a commitment to the patient and the need to advocate and protect the rights of the health and safety of the patient.

A court case in California (Munoz v. Watsonville Community Hospital) has brought to light the continued importance of the nurse's roll in being a patient advocate, even when it might not be easy or popular.

The case, in summary, involves a 27-year-old woman — referred to only as K.M. — who presented to the hospital with abdominal pain twice in one day. On the first ER visit, she was administered an opioid analgesic, after which she was pain free and ultimately discharged.

She returned to the same ER later that morning with her pain resumed. She had a pain level of 10 and was noted to be a "certified medical emergency." During the second ER visit, she was administered Ativan, Haldol and soap-suds enema, but no pain medications. Later, in the early afternoon, she was discharged home with a noted pain of 8 out of 10.

Unfortunately, she continued to deteriorate at home and was found by EMS in cardiac arrest. She subsequently died the following day.

Although the courts did grant a motion to dismiss the accusation of an EMTALA violation in relation to the appropriate medical screening, they noted that the facility failed to stabilize the identified emergency condition and improperly transferred a patient who was not stabilized.

In essence, the court identified the hospital staff — essentially the nurses — as responsible parties in failing to stabilize the patient. It appears from the case records that the nurse simply documented the pain of 8 and discharged the patient as ordered by the physician.

This case highlights the legal and ethical obligation of the ER nurse to question an order when a patient's condition warrants such intervention. In this case, the nurse had knowledge that the patient continued to be in pain, yet was allowed to go home without proper interventions or diagnostics.

Nurses have training and knowledge to know that a person coming into the emergency room should be afforded some resolution of their complaints or at least a viable plan of care prior to discharge. This is where the nurse's role for advocacy is paramount, but not always easy. In a busy healthcare environment, it is not always easy or encouraged to stop the flow, however, the patients are relying on the nurse to do just that.

Often, there is a perceived gray area when questioning an order or decision is seen as overstepping boundaries. But blindly following orders does not protect the nurse from liability or the patient from injury, especially when the orders are suspect.

The Supreme Court of Ohio in Becdyck v. Shinde described it clearly:

"A nurse who concludes that an attending physician has misdiagnosed a condition or has not prescribed the appropriate course of treatment may not modify the course set by the physician simply because the nurse holds a different view. To permit that conduct would allow the nurse to perform tasks of diagnosis and treatment denied to the nurse by law.

"However, the nurse is not prohibited from calling on or consulting with nurse supervisors or with other physicians on the hospital staff concerning those tasks when they are within the ordinary care and skill required by the relevant standard of conduct."

In other words, not only is questioning or investigating a concern appropriate, but is part of the expectations of nursing care.

Anyone working in a busy ER can see how easily a patient can slip through the cracks, but it does not make it right or acceptable. When most became nurses, they saw no problems with following all aspects of the code of ethics and made a personal obligation to do the best for their patients every time. But as the stress and politics of the workplace begin to seep into care provided, the adherence becomes more challenging.

So although it may be simple in theory, in becomes complicated in practice.

However, it is from cases such as this that we take the time to step back, regroup and reset our practice to the way we want it to be — the way it was intended and presented in school. Otherwise, patients will continue to be harmed, and no one wants that.

Joan Spitrey has been a registered nurse for more than 16 years, specializing in critical care and acute care services. She currently is a clinical nursing instructor, sharing her passion with the next generation of nurses. She can be found blogging at TheNurseTeacher.com.