NSG210 Durham Ch. 2: Ethics and Standards of Practice Issues

Source: Durham & Chapman, Maternal-Newborn Nursing: The Critical Components of Nursing Care 4e, Chapter 2, pp. 19-36 (textbooks/DURHAM_OB_CH02.pdf, also in textbooks/exam01/). Exam 1 reading (“Ethics/standards of practice” is on the Exam 1 OB test map). See also nsg210-week-03-summary.

Learning Outcomes

1. Debate ethical issues in maternity nursing.
2. Explore standards of practice in maternity nursing.
3. Describe legal issues in maternity nursing.
4. Analyze evidence-based practice (EBP) and challenges in research utilization in the perinatal setting.

I. Ethics vs Morality

• Morality: personal, adaptable over time; many standards in a pluralistic society
• Ethics: disciplined study of morality expressed as systematic norms
• Nursing ethics are codified in the ANA Code of Ethics (2015) and are binding regardless of a nurse’s personal morality

II. ANA Code of Ethics (Table 2-1)

Purpose: nonnegotiable ethical standard; the profession’s commitment to society; statement of every nurse’s duties; resource for ethical dilemmas.

1. Practice with compassion and respect for the inherent dignity, worth, and uniqueness of every person
2. Primary commitment is to the patient (individual, family, group, community)
3. Promote, advocate for, and protect the health, safety, and rights of the patient
4. Authority, accountability, and responsibility for nursing practice and decisions
5. Same duties to self as to others: health, safety, integrity, competence, growth
6. Establish, maintain, and improve the ethical environment of the work setting
7. Advance the profession through research, scholarly inquiry, standards, and policy
8. Collaborate with other professionals and the public to promote human rights and reduce disparities
9. The profession articulates nursing values, maintains integrity, and integrates social justice into nursing and health policy

III. Ethical Principles

• Maternity nursing is unique: two patients (woman and fetus); decisions change with gestational age (ethical at 12 weeks may not be at 35 weeks)
• Viability: the point when a fetus can survive outside the uterus with reasonable probability of growing and developing; NICU technology blurs this line

A. Ethical approaches to limited resources

• Utilitarianism: greatest good for the greatest number; opposes large resources for a few
• Libertarianism: some people are more valuable to society and should get the resources they need
• Egalitarianism: all people are equal; distribute by need to protect the marginalized and vulnerable
• Example: should a premature infant’s lifesaving support depend on the family’s ability to pay, or on likely disability?

B. Ethical dilemmas

• A choice between equally desirable or undesirable alternatives; also when patient rights conflict with professional obligations
• A capable pregnant woman may refuse recommended treatment, even life-sustaining treatment; her refusal should be respected (ACOG)
• Primary duty is to the pregnant woman; this usually also benefits the fetus; when interests diverge, the duty to the woman takes priority
• The woman’s autonomy includes decisions not in the fetus’s best interest (for example continuing high-risk behaviors) or forgoing her own treatment (delaying chemotherapy)
• Nurse does not voice approval or disapproval; advocates for informed decisions
• Prevent dilemmas with EBP-based safe practice, a culture of safety, and reporting errors
• Use cultural awareness and cultural humility; support women’s choices

Perinatal dilemma examples (Box 2-1):

• Court-ordered treatment; maternal vs fetal rights
• Withdrawal of life support
• Fetal organ or tissue harvesting; anencephalic infant organs
• In vitro fertilization and disposal of fertilized ova
• Resource allocation in the previable period; equal access to prenatal care
• Fetal surgery; treatment of genetic disorders or abnormalities found on screening
• Cloning, genetic engineering, surrogacy
• Drug testing and criminalization of substance use in pregnancy
• Sanctity of life vs quality of life for extremely premature or disabled infants; resuscitation at borderline viability
• Fetal reduction; sex selection; preconception gender selection

Ethics committee:

• Advisory group appointed by the hospital medical executive board; doctors, nurses, lawyers, clergy; staff or family may request a consult

Moral distress (Clinical Judgment):

• Acting against one’s better judgment because of internal or external constraints; threatens moral integrity; common in health care
• Nurses who internalize professional ethics are less likely to lose confidence and self-esteem
• Moral courage: speak up, ask questions, self-reflect on personal values to respect others’ values
• Common triggers: abortion, near-viability resuscitation, end-of-life care, informed refusal, withdrawal of treatment

C. Ethics in neonatal care

NICU categories:

• Aggressive care probably futile (extremely poor prognosis)
• Aggressive care probably beneficial (excellent chance of good outcome)
• Effect of aggressive care uncertain

Key points:

• Families sometimes request futile care; nurses still advocate for appropriate care
• Veracity: keep parents fully informed; withholding information to protect them is paternalism (an authority figure choosing for others) - disrespectful and inappropriate
• Parents live with long-term consequences; build consensus with team and parents; acknowledge concerns
• Nurses interact with families more than any other professional; increase parent participation in daily care and decisions
• Moral distress common in NICU (end-of-life, periviable resuscitation, futility)
• When treatment is clearly beneficial, the baby’s right to treatment outweighs parents’ rights; when benefit is unclear, ethicists and courts defer to parents
• Newer approach focuses on the process: help parents discern their own values and understand the prognosis and the meaning of choices
• Disagreements resolved by ongoing discussion, involving family, or ethics consultation

IV. Ethical Decision-Making: Jonsen “Four Topics” Method

Sorts case data to find where the problem lies; does not give an answer.

1. Medical indications (beneficence, nonmaleficence): diagnosis, history, prognosis; acute, chronic, critical, reversible; goals of treatment; probability of success; how can patient benefit and harm be avoided
2. Patient preferences (autonomy): informed of risks and benefits, understood, consented; prior preferences or advance directives; unwilling or unable to cooperate and why; is the right to choose respected
3. Quality of life (beneficence, nonmaleficence, autonomy): prospects for return to normal life; expected deficits; provider bias; whether continued life might be undesirable; plans for comfort and palliative care
4. Contextual features (loyalty, fairness): family issues, finances, religion and culture, resource allocation, law

A. Health disparities and equity

• SDOH (where people are born, live, work, age) are as important as genetics and lifestyle
• Health equity requires correcting injustices for marginalized groups with intersectional identities
• Data show worse perinatal outcomes for Black women; structural racism and discrimination are not equally experienced
• CDC health equity: everyone has the opportunity to be as healthy as possible
• Birth equity: assurance of conditions of optimal births for all people with a willingness to address racial and social inequalities in a sustained effort
• Disparities operate at individual (SES, race, gender, behaviors, biology), intermediate (neighborhood, community, social networks), and structural (policies, institutions) levels

B. Cultural humility (Tervalon and Murray-Garcia)

1. Critical self-reflection and lifelong learning
2. Recognizing and mitigating power imbalances
3. Mutually beneficial, nonhierarchical partnerships with communities, amplifying community expertise
4. Institutional alignment and accountability

V. Nurses’ Rights and Responsibilities (AWHONN)

• Nurses have a federally protected right to refuse to participate in procedures that conflict with personal moral, ethical, or religious beliefs
• But nurses must:
  • Not abandon a patient or refuse care because of prejudice or bias
  • Provide high-quality impartial care in emergencies regardless of personal beliefs
  • Inform employers of beliefs that may interfere with essential job functions
• AWHONN core values (CARING): Commitment to professional and social responsibility; Accountability; Respect for diversity; Integrity; Nursing excellence; Generation of knowledge

VI. Standards of Practice

• ANA definition of nursing: protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through diagnosis and treatment of human response, and advocacy for individuals, families, groups, communities, and populations
• AWHONN standards represent optimal practice; they are guidelines, not employment, licensure, or legal standards; the best interest of the individual patient is the touchstone; nurses also follow law and institutional policy

AWHONN Standards (Box 2-2):

• Standards of care (nursing process): 1 Assessment, 2 Diagnosis, 3 Outcome identification, 4 Planning, 5 Implementation (5a Coordination of care; 5b Health teaching and health promotion - new), 6 Evaluation
• Standards of professional performance: 7 Ethics, 8 Culturally congruent practice, 9 Communication, 10 Collaboration, 11 Leadership, 12 Education, 13 Evidence-based practice and research, 14 Quality of practice, 15 Professional practice evaluation, 16 Resource utilization, 17 Environmental health

Key terms (Table 2-2):

• Cultural congruence: evidence-based care that agrees with the consumer’s cultural values and practices
• Cultural sensitivity: responsive to attitudes and circumstances of groups with shared heritage
• Equity: absence of unnecessary or remediable differences among groups
• Family-centered maternity care: integrates physical, sociocultural, psychological, spiritual, economic needs of the woman and family (however defined); requires trust and collaboration
• Oppression: dominant group treats outsiders as inferior; oppression of practice when nurses cannot practice to the full extent of education and license
• Social justice: all persons treated equitably regardless of diversity
• Standards of practice: competent clinical practice through the nursing process
• Standards of performance: competent behavior in the professional role

VII. Legal Issues

• Maternity is the most litigious practice area (two patients at once; expectation of a perfect outcome)
• OB claims are about 5% of malpractice claims but up to 35% of a hospital’s financial liability
• EBP is the gold standard in malpractice cases
• “Failure to communicate” is a major issue in most suits against nurses; communication problems between providers in nearly half of cases; also failure to appreciate clinical decline and to escalate concerns
• Dissatisfaction with interpersonal interaction makes patients more likely to sue; technology may interfere with caring interaction
• OB malpractice claims declining with team communication and EFM initiatives

Five situations account for most fetal and neonatal injury litigation:

1. Failure to recognize or respond to intrapartum fetal compromise
2. Failure to perform a timely cesarean (30 minutes from decision to incision)
3. Failure to appropriately resuscitate a depressed neonate
4. Inappropriate use of oxytocin or misoprostol leading to tachysystole, uterine rupture, fetal intolerance of labor, or fetal death
5. Inappropriate use of forceps or vacuum, or preventable shoulder dystocia

A. Fetal monitoring

Common allegations:

• Failure to accurately assess maternal and fetal status
• Failure to appreciate deteriorating fetal status
• Failure to treat an abnormal or indeterminate FHR
• Failure to reduce or stop oxytocin with an abnormal or indeterminate FHR
• Failure to communicate maternal and fetal status to the provider
• Failure to use the chain of command in a clinical disagreement

AWHONN position:

• Nurses should complete a course in physiologic EFM interpretation
• Each facility needs a policy defining when to use EFM vs auscultation, frequency, documentation
• Use uniform FHR terminology for communication and defensible documentation
• Systems must support timely response to Category II (indeterminate) and Category III (abnormal) tracings

Chain of command:

• The nurse must initiate action when maternal or fetal well-being is at stake
• If the provider does not respond to an abnormal FHR or deterioration, use the chain of command to advocate for safety
• First level: notify the immediate supervisor; further steps per institutional policy

B. Risk management

• Systems approach to identify and treat risks before suits
• Avoid preventable fetal harm: competent providers, consistent FHR language, systems for timely intervention
• Reduce liability: documentation showing appropriate, timely care before, during, after interventions
• Two tenets: (1) use evidence and published standards as the foundation of care; (2) put patient safety ahead of convenience, productivity, and cost
• The most defensible actions focus solely on patient well-being; AWHONN staffing guidelines support safe care

VIII. Evidence-Based Practice

• EBP: integrate best current evidence with clinical expertise and patient/family preferences and values (QSEN)
• Research creates generalizable knowledge; EBP applies evidence in practice; translation science studies how to implement evidence
• Components: best research evidence (quantitative and qualitative), clinical expertise, patient values
• Guideline resources: Guideline Central (after AHRQ National Guideline Clearinghouse was defunded in 2018)
• Cochrane Reviews: systematic reviews and meta-analyses of RCTs; RCT is the gold standard

Hierarchy of evidence (Fig. 2-3, highest to lowest):

1. Systematic reviews and meta-analyses
2. Experimental designs (RCTs, pseudo-RCTs)
3. Quasi-experimental designs
4. Observational-analytic (cohort, case-control)
5. Observational-descriptive (cross-sectional, case series, case study)
6. Background information and expert opinion

Qualitative research:

• Critics say RCT-centered EBP ignores the context and experience of nursing; most experts now accept both quantitative and qualitative evidence
• Qualitative research studies real-world phenomena, context, and relationships; its stories communicate findings compellingly to staff and policy makers
• Evaluate qualitative findings for context, generalizability, fit with practice

Critical Component - fostering EBP:

• Locate reliable evidence reports and guidelines
• Question routine approaches that give poor outcomes
• Base individualized care on patient values, expertise, and evidence

A. Research utilization challenges

• Continuous EFM (Cochrane, Alfirevic 2017): reduces neonatal seizures but no difference in cerebral palsy, infant mortality, or other neonatal measures; increases cesarean and operative vaginal births
• Intermittent fetal monitoring (IFM, “high touch, low tech”): recommended for low-risk labor; fewer cesareans, same newborn outcomes, more freedom of movement, less pain, faster descent - yet rarely used
• Barriers to IFM: time and nurse-to-patient ratios; continued EFM use reflects habit, convenience, liability, staffing, economics
• Nurses should not keep doing things the way they always have without questioning

B. Barriers to EBP

• Inadequate EBP knowledge and skills
• Lack of supportive cultures
• Belief that EBP takes too much time
• Outdated policies; limited resources and budget
• Resistance from colleagues and leaders
• Too few EBP mentors
• Academic programs teaching how to conduct research rather than use evidence
• Systematic review: lack of awareness, no authority to change practice, too many publications, lack of compiled literature; facilitators - organizational and colleague support, continuing education

C. Strategies to enhance EBP

• Nursing clinical effectiveness committee to develop and implement guidelines
• Screen for SDOH to advance equity
• Education: grand rounds, simulation, skills fairs, posters, one-on-one meetings, case conferences
• Melnyk steps: (0) cultivate a spirit of inquiry; (1) ask a PICOT question (Patient population, Intervention or issue, Comparison, Outcome, Time); (2) search for best evidence; (3) critically appraise; (4) integrate with expertise and patient preferences; (5) evaluate outcomes; (6) disseminate

D. AWHONN nurse-sensitive quality measures (Box 2-4)

• Triage by RN or nurse-midwife within 10 minutes of arrival
• Mother-initiated spontaneous pushing in second stage
• Skin-to-skin within 5 minutes of birth for healthy term newborns
• Uninterrupted skin-to-skin for at least 60 minutes
• No supplementation (water, glucose water, formula) of breast-milk-fed healthy term newborns without medical indication
• Protect milk volume for NICU premature infants: breast pump and RN instruction, with the nurse present for the first pumping within 6 hours of birth
• Referral hospital NICU nurse phones the mother within 4 hours of infant arrival after transport
• Perinatal grief support after loss
• Annual women’s health and wellness screening
• Continuous labor support by RN or certified doula
• Partial labor support: nonpharmacologic support from an RN at least once every hour
• Freedom of movement during labor

High-Yield Numbers

• Cesarean decision to incision: 30 minutes
• OB claims: about 5% of malpractice claims, up to 35% of hospital liability
• Triage within 10 minutes; skin-to-skin within 5 minutes and for at least 60 minutes; first pumping within 6 hours; NICU call to mother within 4 hours; partial labor support at least hourly
• ANA Code of Ethics: 9 provisions
• AWHONN standards: 6 standards of care, 11 standards of professional performance (17 total)

Priority Nursing Actions

• Respect a competent woman’s informed refusal; advocate without judging
• Primary duty is to the pregnant woman
• Keep families fully informed; avoid paternalism
• Use the four topics method and ethics committee for dilemmas
• Speak up (moral courage); recognize moral distress
• Use uniform FHR terminology; respond to Category II and III tracings; reduce or stop oxytocin for abnormal FHR
• Use the chain of command when a provider does not respond - start with the immediate supervisor
• Document timely, appropriate care
• Do not refuse care based on bias; give emergency care regardless of personal beliefs; tell employers of conscientious objections in advance
• Base care on evidence, expertise, and patient values

Related

• nsg210-durham-ch01-trends-and-issues
• nsg210-week-03-summary
• INDEX