CHAPTER 2. Standards for Ethical Practice
Barbara A. Godden
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Describe the importance of standards as they relate to perianesthesia nursing practice.
2. Describe the contents of the American Society of PeriAnesthesia Nurses (ASPAN) Standards of Perianesthesia Nursing Practice.
3. Define competency-based practice.
4. Identify important ethical principles.
5. List the steps for ethical decision-making.
I. DEFINITION OF STANDARD
A. Established by authority, custom, or general consent
B. Model for quality or quantity
C. Standardized for everyone
D. Determined by what a reasonably prudent nurse acting under the same circumstance would do
E. Describes the responsibilities for which the nursing profession is accountable
F. Provides direction for professional nursing practice
G. Framework for the evaluation of care
II. EVOLUTION OF NURSING STANDARDS
A. Before 1950
1. Florence Nightingale
2. Reports of court cases
B. Code of Ethics published by the American Nurses Association (ANA) in 1950
1. Nursing care without prejudice
2. Confidential care
3. Safe care
C. Standards of professional nursing practice
1. Pertain to general or specialty practice
2. First generic nursing standards in 1973 by the ANA Congress for Nursing Practice
3. Specialty standards followed beginning in 1974.
III. SOURCES OF STANDARDS
A. Accrediting organizations
1. The Joint Commission (TJC)
2. Accreditation Association for Ambulatory Healthcare
3. American Association for the Accreditation of Ambulatory Surgical Facilities
B. ANA
C. Hospital policies and procedures
D. Specialty organizations
E. Nursing texts and articles
F. Common practice
IV. STANDARD CRITERIA
A. Standard: authoritative statement articulated and disseminated by the profession by which the quality of practice, service, or education can be judged
B. Rationale: delineates the importance to perianesthesia practice
C. Outcome: measures the results of activity (per The Joint Commission, care should meet the same standards of practice wherever the care is provided)
D. Criteria: describes principles and actual activities used in implementing practices to meet the standard
V. ANA STANDARDS— NURSING: SCOPE AND STANDARDS OF PRACTICE
A. Original standards published in 1973
B. Apply to all registered nurses in clinical practice
C. Standards of care: describe a competent level of nursing care
1. Assessment: collect pertinent patient health information
2. Diagnosis: analyze assessment data to determine nursing diagnosis
3. Outcome identification: identify individualized expected patient outcomes
4. Planning: develop a plan of care specific for the patient
5. Implementation: implement nursing interventions identified in the plan of care
6. Evaluation: evaluate patient’s outcomes on an ongoing basis
D. Standards of professional performance: describe a competent level of behavior in the professional role
1. Quality of care: systematic evaluation of the quality and effectiveness of the nursing practice
2. Performance appraisal: evaluate own nursing practice with professional practice standards and any relevant regulations
3. Education: maintain current knowledge and competency in nursing practice
4. Collegiality: interact and contribute to the professional development of peers and other health care providers
5. Ethics: decision-making and advocating ethical actions on behalf of the patient
6. Collaboration: work together with other heath care providers, the patient, and family for patient care
7. Research/evidence-based practice (EBP): review and incorporate research and EBP findings into daily nursing care
8. Resource utilization: utilize research findings for individualized patient care
VI. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY, FORMERLY THE AGENCY FOR HEALTHCARE POLICY AND RESEARCH
A. Established in 1989
B. Goal to enhance quality, appropriateness, effectiveness of health care
C. Standard of practice: patients will receive care according to the standard
D. Guideline: to guide practitioners, patients, and consumers in health care decisions
E. First guidelines in 1992: Acute Pain Management goals:
1. Reduce the incidence and severity of patients’ acute postoperative or posttraumatic pain.
2. Educate patients about the need to communicate unrelieved pain.
3. Enhance patient comfort and satisfaction.
4. Contribute to fewer postoperative complications and shorter lengths of stay.
VII. STANDARDS OF PERIANESTHESIA NURSING PRACTICE 2008–2010
A. ASPAN history of standards
1. 1983: Guidelines for Standards of Care published
2. 1986: Standards of Nursing Practice published
3. 1989: definition expanded to include preoperative and phase II areas
4. 1991: Standards of Post Anesthesia Nursing Practice published; included data for initial, ongoing, and discharge assessment for phase I and phase II
5. 1992: Standards of Post Anesthesia Nursing Practice published
6. 1995: Standards of Perianesthesia Nursing Practice published; included preanesthesia, preprocedural, phase I and phase II postanesthesia information
7. 1998: Standards of Perianesthesia Nursing Practice, revised; included the addition of postanesthesia phase III for patients requiring extended observation
8. 2000: Standards of Perianesthesia Nursing Practice, revised
9. 2002: Standards of Perianesthesia Nursing Practice, revised
10. 2004: Standards of Perianesthesia Nursing Practice, revised
11. 2006: Standards of Perianesthesia Nursing Practice, revised
12. 2008: Standards of Perianesthesia Nursing Practice, revised
B. Perianesthesia nursing scope of practice
1. Assessment, diagnosis, intervention, evaluation of physical and psychosocial problems, and risk for problems resulting from the administration of sedation, analgesia, and/or anesthetic agents and techniques
2. Nursing practice is systematic in nature and includes:
a. Nursing process
b. Decision-making
c. Analytical and scientific thinking
d. Inquiry
3. The scope of practice includes, but is not limited to:
a. Preanesthesia level of care
(1) Preadmission
(2) Day of surgery/procedure
b. Postanesthesia levels of care
(1) Phase I
(2) Phase II
(3) Extended observation
4. The environment of care includes, but is not limited to:
a. Hospitals
b. Ambulatory surgery units (ASUs)/centers
c. Procedure areas (i.e., cardiology, electroconvulsive therapy, GI/endoscopy, interventional and diagnostic radiology, oncology, pain management, etc)
d. Labor and delivery
e. Office-based settings
C. Perianesthesia nursing encompasses the following continuum of care:
1. Preanesthesia phase
a. Preadmission: preparation, interviewing, assessment, identification of potential or actual problems
b. Day of surgery/procedure: validation of existing information; completion of preparation
2. Postanesthesia phase I: immediate postanesthesia period; basic life-sustaining needs, constant vigilance
3. Postanesthesia phase II: prepare the patient/significant other for home or extended care environment
4. Extended observation (formerly phase III): provide ongoing care for patients requiring extended observation/intervention after discharge from phase I or phase II
D. The scope of perianesthesia nursing practice is regulated by:
1. Hospital or facility policies and procedures
2. State and federal regulatory agencies
3. National accreditation bodies
4. Professional nursing organizations
E. Perianesthesia nursing interacts with other professional groups to advance the delivery of quality care. These groups include but may not be limited to:
1. American Association of Colleges of Nursing (AACN)
2. American Association of Critical Care Nurses (AACN)
3. American Association of Nurse Anesthetists (AANA)
4. American Association of Surgical Physician Assistants (AASPA)
5. American Board of Perianesthesia Nursing Certification (ABPANC)
6. American College of Surgeons (ACS)
7. ANA
8. American Radiologic and Interventional Nurses (ARIN)
9. American Society of Anesthesiologists (ASA)
10. American Society of Pain Management Nurses (ASPMN)
11. American Society of Plastic Surgery Nurses (ASPSN)
12. Anesthesia Patient Safety Foundation (APSF)
13. Association of Surgical Technologists (AST)
14. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
15. Association of periOperative Registered Nurses (AORN)
16. British Anaesthetic & Recovery Nurses Association (BARNA)
17. Council on Surgical and Perioperative Safety (CSPS)
18. Foundation for Ambulatory Surgery Association (FASA)
19. Irish Anaesthetic & Recovery Nurses Association (IARNA)
20. National Association of Perianesthesia Nurses of Canada (NAPNC)
21. National League for Nursing (NLN)
22. National Student Nurses Association (NSNA)
23. Nursing Organizations Alliance (NOA)
24. Society for Ambulatory Anesthesia (SAA)
25. Society of Gastroenterology Nurses and Associates (SGNA)
26. Society for Perioperative Assessment and Quality Improvement (SPAQI)
27. Society of Office-Based Anesthesia (SOBA)
F. Perianesthesia standards for ethical practice
1. Specific context in which to apply the ANA Code of Ethics
2. Moral commitment to uphold values and ethical obligations related to perianesthesia nursing
3. Strive to ensure:
a. Competency
(1) Maintains personal accountability
(2) Participates in professional continuing education
(3) Adheres to ASPAN’s standards
(4) Complies with institutional policies and procedures
(5) Accepts responsibility/accountability
(6) Participates in performance improvement
(7) Uses competency-based orientation
(8) Remains current on new products/procedures
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