nursing ethical dilemma in emergency department
Countless emergency departments are literally on life support as they try to cope with capacity issues and workforce shortages. Nursing services in the Emergency Department (ED) focus on maintaining clinical credibility and articulates the vision and philosophy of the healthcare service as well as to promote the art and science of Emergency Nursing. Nurses must also act fairly to all persons regardless of gender, race, socioeconomic status, cultural background, or the ability to pay. Related to beneficence is the corollary of non-maleficence, which is an obligation not to harm others. In 2015, the emergency department at Medway Foundation Trust was experiencing a critically high nursing vacancy rate. (2005, June 8). This represents a denial of access to care and puts patients at risk for harm. Juana was the driver of a sedan involved in a single-vehicle collision. Emergency department (ED) utilization continues to outpace population growth. While there tends to be a lot of flashing lights and a good bit of chaos, there are true moments of greatness and connection with your patients that you won't find anywhere else in healthcare. (2007). Ethics & Medicine, September. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. By the end of the collaborative, we saw over twenty-five different strategies used by these motivated hospitals to reduce their LBBS rates and boarding times (McClelland, 2014). What is the chronology of events? In the ED, staff must be especially aware of this concept because of time constraints, or absence of relatives or ability to communicate with the patient. Critical Care Medicine, 35, 1477-1483. 2. If we can fix EDs, we can fix all of healthcare. Nursing in the ED is a complex and specialized practice where highly complex, and invasive interventions are often executed without obtaining informed consent from the patient or the surrogate. A new, evidence-based estimate of patient harms associated with hospital care. For every task there is a designated location and frequently a delay. This study used reflective essays and debriefing sessions to show the kinds of ethical dilemmas experienced by medical students. Research has demonstrated that ED crowding causes higher rates of complications and has been implicated as a cause of greater in-hospital mortality (Bernstein, et al., 2009; Chalfin, Trzeciak, Likourezos, Baumann, & Dellinger, 2007). NURSES’ ETHICAL CONSIDERATIONS IN A PANDEMIC OR OTHER EMERGENCY AUGUST 2008 ISSN NUMBER 1480-9990 “The nursing profession plays an integral role in all aspects of emergencies, including mitigation, preparedness, response and recovery” (CNA, 2007, p. 1). Therefore, nurses’ experiences can provide vital information about the decisions and dilemmas in clinical practice that affect both healthcare professionals and patients alike. More explicit training on ethics in the clinical years may minimize the effect of the hidden curriculum. One hospital I worked with eliminated the waiting room itself. Although algorithms are available to guide care in cases of cardiac arrest and trauma, each patient and situation is unique, and deviations from protocol may be indicated. Inspectors had visited the department in December after performance data flagged that national targets for waiting times were not being met, meaning patient safety could be at risk. To shine a light on these ED processes, the Centers for Medicare and Medicaid Services (CMS) has recently required hospitals to measure and report their LBBS rates and boarding times. Retrieved from www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/promising-practices/alleviating-crowded-eds.html, Stanford Encyclopedia of Philosophy. Citation: McClelland, M., (March 6, 2015) "Ethics: Harm in the Emergency Department - Ethical Drivers for Change" OJIN: The Online Journal of Issues in Nursing Vol. His professional interests include performance measurement, redefining primary care, creating high reliability organizations, reducing clinical practice variation and the integration of evidenced-based care. Though some have taken their concerns … h) recognise the cultural and ethnic issues in relation to the care of a patient and evaluate the nurse’s role, attitudes and values in care of patients presenting to the emergency department. Academic Emergency Medicine, 21, 1092–1100. Autonomy brings with it an obligation to respect the choices of others, such as a patient’s right to self-determination. As these boarded patients consume an increasing share of the ED’s resources, waiting times throughout the ED, and especially in the waiting room, increase to often unsafe levels. The first author followed nurses, medical secretaries and doctors in the emergency department. In essence, futile treatments are those that preserve permanent states of unconsciousness, or fail to end a patient’s total dependence on intensive medical treatment (University of Washington School of Medicine, 1998).6. Emergency nurses make a difference in the lives of people every day, every shift. Write clearly and logically, with correct use of spelling, grammar, punctuation, and mechanics. When patients arrive in the ED, the triage nurse has little time to gather detailed information. Vision /? 4. 5. Emergency nurses work in a fast-paced, often-stressful environment that requires a unique skill set above and beyond the standard nursing skills. It is informed by best evidence and research. Alfandre, D. (2009). (2009). As a case manager in a busy, urban, intensive care unit, barely a day went by during rounds when we did not discuss a patient that, (a) was at risk for…or, (b) was suspected of having…, or (c) had developed…, or, (d) was critically ill fighting off…, or (e) had just died from…a central line infection. Indeed, EDs have been recognized as the safety net for the under-insured and uninsured. For those who are not competent or are unable to sign the consent forms, a surrogate will then assume responsibility. (2008). This study highlights the variation in ability to nurse‐initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients. When a person makes the decision to seek ED care, they are acting to meet an important personal need. Retrieved May 11, 2011, from http://www.depts.washington.edu/bioethx. Nurses who work in an emergency department regularly care for acute patients in a fast-paced environment, being at risk of suffering high levels of burnout. Retrieved from www.ihi.org/resources/Pages/Tools/EDFastTrackTool.aspx. The new paradigm takes advantage of parallel processes. Emergency care providers regularly deal with ethical dilemmas that must be addressed. Eyewitness News ABC 7. Promising practices for improving emergency department operations. Retrieved from http://7online.com/archive/9404603/, Institute for Healthcare Improvement. Download Citation | On May 1, 2009, Jason W Grimm and others published Illegal Immigrants in the Emergency Department: An Ethical Dilemma for Nurses? Favorites; PDF. This care is prioritised in the following way: Dilemmas and opportunities for an appropriate health-service response to violence against women. The traditional model of ED care is linear in nature: arrival > check- in > triage > registration > waiting room > treatment room > physician evaluation > testing > treatment room > disposition. Additionally, the nurse needs to ensure patients understand the potential benefits and success of certain procedures, but that outcomes are not guaranteed. . Retrieved from www.acep.org/Clinical---Practice-Management/ACEP-Unveils-Boarding-Solutions-Report/. Unpublished manuscript. In emergency department triage, medical care might lead to adverse consequences like delay in providing care, compromise in privacy and confidentiality, poor physician … . Proposed revisions to public health statutes require some health professionals to give care in an emergency as a condition of licensure [47]. Background. It was not until Peter Pronovost came along and virtually eliminated CLABSI at Johns Hopkins Medical Center, and then validated his work by eliminating CLABSI throughout the state of Michigan, that we, as an industry, began to see there was another way (Pronovost et al., 2010). The expectation of services in the ED is to treat patients as well as inform them of their medical conditions. Emergency Nurses Association. This system can include consideration of the following issues: Who are the stakeholders? Yet, healthcare providers work every day in settings prone to causing harm. To address this, a comprehensive, structured recruitment and retention strategy was introduced. Today, despite the development of a robust patient safety movement fueled by the IOM report, hospitalization is the third leading cause of death accounting for upwards of 400,000 preventable deaths/year (James, 2013). While the specific strategies were important, it was crucial that ED leadership and clinicians were willing to reimagine the way in which the ED did business. Emergency Nursing – Is it right for you? Aim: The aim of this study was to explore the perceptions of nursing staff in an English emergency department in relation to their ethical, legal and professional accountability. This is achieved when patients are competent to agree or disagree to with proposed interventions and can sign consent their name. This stipulation was included in the Hill-Burton law of 1946 that jump-started the hospital industry by paying for new hospital construction; it was codified more clearly in the law called the Emergency Treatment and Active Labor Act (EMTALA) of 1986. Nurses confront doubts about their accountability and how it affects their clinical practice daily in the complex environment of an emergency department. The Mackay Base Hospital Emergency Department is a mixed Emergency Department (ED) with an approximate 50,000 emergency presentations per year. It is the role of the ED nurse to ensure patients have accurate and comprehensive information to make informed decisions regarding treatment. Comparison of High-Sensitivity … Ethical dilemmas in Emergency Medicine 4: The ethics of triage Rick Body on August 30, 2014 It’s been a while since we published our last ‘Ethical Dilemmas’ post at St. Emlyn’s. Instead of being a ‘push’ organization, where ED staff struggled to get admitted patients to the nursing units (one hospital reported that on average 13 telephone calls were required to admit a patient), hospitals identified and implemented a vision where the nursing units ‘pulled’ patients out of the ED shortly after the decision to admit was made. Google Scholar provides a simple way to broadly search for scholarly literature. Case Study -“Juana” (fictitious name) a 20-year-old, Black Hispanic female, 32 weeks pregnant, was brought to the emergency department (ED) in an ambulance by the paramedics. All patients have the right to a standard of care as outlined in the Emergency Medical Treatment and Active Labor Act, which mandates access to quality emergency medical treatment to all whom seek it.3. In most clinical settings, there is adequate time to identify and discuss the relevant ethical issues before decisions are made. If a surrogate is not available, attempts will be made to contact one through acceptable modes of communication. Juana was the driver of a sedan involved in a single-vehicle collision. It is just as important, however, to address accessibility, especially for members of the Deaf and Hard of Hearing community. What are the key findings? Retrieved May 10, 2011, from http://www.jme.bmj.com. Grimm JW, Wells JL J Emerg Nurs. In 1999, the Institute of Medicine (IOM) reported hospital errors were responsible for 99,000 deaths/year, making hospitalization the fifth leading cause of death in the … Emergency nursing practice is underpinned by expert knowledge gained through specialist education and clinical experience. An overall pleasant experience. As such, EDs can serve as laboratories for reform. DOI: 10.3912/OJIN.Vol20No02EthCol01. Data were also collected by means of semi‐structured interviews. Lateef, F. (2008). Emergency department nursing staff should be PILS/PLS or equivalent trained. the emergency department is unlikely to be governed by one paradigm or theory. Patients must always provide informed consent autonomously and voluntarily. Hospital administrators and ED leaders and providers are not acting with beneficence when they allow excessive waiting times as a predictable occurrence in their EDs. Emergency Nurse Association. To do this, hospitals created ED flow coordinators whose job was to interface with the teams on the nursing units to keep them informed about pending admits. "Is this question part of your assignment? There are many drivers to harm in the healthcare industry. Futility. She arrived in the ED immobilized on a flat board with a hard cervical collar in place. How does the flow culture in an emergency department influence nurses’ use of a research‐based clinical guideline and a nutrition screening routine. Demand forecasting helped nursing units set staffing levels based on predicted admissions rather than the midnight census. (1998). Legal and Ethical Issues in Nursing in the Emergency Department . Ethical issues are hardly considered in emergency department setting. The primary cause of ED crowding is the practice of holding, or boarding, admitted patients in the ED (IOM, 2007). Introduction: Moral distress in nursing has been studied in many settings, but there is a paucity of research on moral distress as it manifests in the emergency department. ED Fast Track Criteria. Recognizing that ED crowding is a hospital problem, not an ED problem, The Joint Commission placed its ‘ED patient flow’ standard in the Leadership domain. Ethical problems are often exacerbated by time constraints, lack of detailed information, and a high incidence of impaired cognitive abilities in the patients. McCusker. 5. Additionally, consideration that future treatments may be futile is not basis to terminate all current treatments from being performed. Journal of Patient Safety, 9, 122-128. doi:10.1097/PTS.0b013e3182948a69. 3. (2007). Additionally, it is the responsibility of the nurses to protect themselves, their coworkers and their patients against violent acts by known perpetrators, other patients or visitors. Now that we know there is a delivery system that results in the virtual elimination of LBBS and boarding time, are all hospitals ethically bound to implement the best practices tested and shown to mitigate ED crowding? The post Legal and Ethical Issues in Nursing in the Emergency Department appeared first on My Nursing Paper. Philosophy of Emergency Nursing Nursing services in the Emergency Department (ED) focus on maintaining clinical credibility and Beneficence is most frequently associated with individual actors, i.e. He believes the best way to ensure safety and quality in healthcare is to create care cultures that value the identification, adoption, integration, and dissemination of best practices. Citation: McClelland, M., (March 6, 2015) "Ethics: Harm in the Emergency Department - Ethical Drivers for Change" OJIN: The Online Journal of Issues in Nursing Vol. A case study demonstrates an ethical dilemma faced by healthcare providers who care for and treat Jehovah's Witnesses who are placed in a critical situation due to medical life-threatening situations. Emergency Department Nursing Orientation Manual Emergency Nurse Orientation Description Emergency nursing is a specialty of nursing practice that is both autonomous and collaborative. Working in the emergency department gives rise to unique ethical considerations. Ethics in the Emergency Room. Just like the wide variation that exists in emergency medicine and emergency departments, there are so many different types of Emergency Nurses. Mandatory Reporting of Intimate Partner Violence: An Ethical Dilemma for Forensic Nurses. Again, a paradigm shift was called for. When patients arrive in the ED, the triage nurse has little time to gather detailed information. When violence is beyond that which can be handled by the nursing staff, then authorities must be brought in. Since 1999, visits have risen from 103 million (378 visits/1000 persons) to almost 130 million (428 visits/1000 persons) in 2010 (Centers for Disease Control, 2014). Preparing for or responding to emerging threats such as bioterrorism and SARS only increases the strain on the system. Based on the focus groups with Emergency Department nurses we conclude that violence at work is an everyday danger for Emergency Department nurses, who feel vulnerable and recognise that it is not within their power to solve this issue given the societal component. Consider that it would take two 747 Jumbo Jets crashing every day to approach the number of annual deaths attributed to hospital medical errors. (2011). In such cases it is incumbent upon nurses to determine the capacity of the patient, evaluate the quality of the delivered information including risks and benefits, and a full documentation of the process. Emergency department (ED) utilization continues to outpace population growth. It is also not uncommon for speciality nurses to operate within accident and emergency departments, but as the name suggests, speciality training and qualifications are needed to fill these roles. Overall, the goals of the ED staff are to quickly treat acute illnesses and injuries, minimize suffering and loss of functioning, and protect life. Triage and check-in both occur on arrival. Journal of Medical Ethics, 29, 4-7. The ED waiting room is sometimes referred to in the popular press as ‘the most dangerous place in the hospital’ because some patients suffer harm due to a long ED wait times (Hoffer, 2014). Hospital based emergency care: At the breaking point. ED nurses must ensure the safety of their patients in their care to the best of their ability. They are expected to participate in their own care while collaborating and cooperating with ED staff, and should respect triage decisions and prioritization. Mayo Clinic Proceedings, 84(3), 255-260. However, providing care with a TIC framework in an ED setting was a considerable challenge primarily due to time constraints relative to the day-to-day ED environment and rapid turnover of patients with We ‘talked’ a lot about central line-associated bloodstream infections (CLABSI), almost as if they were an undesirable, but eventual byproduct of the work we were doing. Vadeboncoeur, Levesque, Ciampi, and Belzile (2014) reported that once an ED was crowded, a 10% increase in ED occupancy led to a 3% increase in inpatient mortality.