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
(9) Practices with compassion and respect
(10) Incorporates research and evidence into practice
b. Responsibilities to patients
(1) Provides quality care
(2) Adheres to safe patient practices
(3) Explains procedures
(4) Maintains patient confidentiality
(5) Participates in patient teaching
(6) Answers questions accurately
(7) Communicates pertinent information
(8) Respects advance directives
(9) Provides communication aids
(10) Advocates for spiritual comfort
(11) Respects patient’s decisions
(12) Protects patients from harm
(13) Advocates for patients
(14) Delegates tasks appropriately
(15) Aggressively provides pain control/comfort measures
(16) Includes the patient’s family and/or support system
(17) Evaluates the patient’s environment for safety
(18) Ensures that all patients are cared for by a registered nurse
c. Professional responsibilities
(1) Adheres to national regulations, standards, facility policies, procedures
(2) Provides comparable level of care regardless of physical setting
(3) Discusses patient information appropriately
(4) Maintains accurate patient records
(5) Safeguards patient confidentiality/information
(6) Participates in activities that contribute to development of the nursing profession
(7) Promotes certification
(8) Acts as a mentor/preceptor
(9) Demonstrates responsible management of resources
(10) Maintains an awareness of changing practice issues
(11) Recognizes a need to care for one’s self
(12) Follows policies, procedures, and laws to protect patients
(13) Identifies/reports unethical practice
d. Collegiality
(1) Collaborates with peers, colleagues, and other health care providers
(2) Promotes respectful relationships with colleagues
e. Research
(1) Identifies problems to be considered for research
(2) Obtains appropriate institutional review board approvals
(3) Protects the rights of research participants
(4) Protects patient confidentiality
(5) Uses evidence and findings to support clinical practice
G. Standards
1. Standard I: Patient rights
2. Standard II: Environment of care
3. Standard III: Staffing and personnel management
4. Standard IV: Performance improvement
5. Standard V: Research
6. Standard VI: Assessment
7. Standard VII: Planning and implementation
8. Standard VIII: Evaluation
H. ASPAN Clinical Practice Guidelines
1. ASPAN Clinical Guideline for the Prevention of Unplanned Perioperative Hypothermia
2. ASPAN Clinical Guideline for Pain and Comfort
3. ASPAN Clinical Guideline for Postoperative Nausea and Vomiting/Postdischarge Nausea and Vomiting
I. Resources in the ASPAN 2008-2010 Standards of Perianesthesia Nursing Practice
1. Nine provisions of the ANA Code of Ethics for Nurses With Interpretive Statements
2. Patient classification and recommended staffing guidelines
a. Preanesthesia phase
(1) Preadmission
(2) Day of surgery/procedure
b. Postanesthesia phase
(1) Phase I level of care
(2) Phase II level of care
c. Extended observation level of care
d. Blended levels of care
3. Components of initial, ongoing, and discharge assessment and management
a. Preadmission
b. Day of surgery/procedure
c. Initial assessment: phase I
d. Ongoing assessment and management: phase I
e. Discharge assessment: phase I
f. Initial assessment: phase II
g. Ongoing assessment and management: phase II
h. Discharge assessment: phase II
i. Initial/ongoing/discharge assessment and management: extended observation
4. Recommended equipment for preanesthesia phase, post anesthesia care unit (PACU) phase I, phase II, and extended observation
5. ASA standards
a. “Statement on Routine Preoperative Laboratory and Diagnostic Screening”
b. ASA “Basic Standards for Preanesthesia Care”
c. ASA “Standards for Postanesthesia Care”
6. Competent support staff
7. ANA position statement: “Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural, or Peripheral Nerve Catheters)”
a. AWHONN Position Statement: “Role of the Registered Nurse in the Care of the Pregnant Woman Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters)”
8. “The Role of the Registered Nurse in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures”
9. Safe transfer of care
10. ASPAN 2006 Internet resources
11. TJC Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
12. Recommended Competencies for the Perianesthesia Nurse
13. Resource for Infection Control
J. ASPAN position statements in the 2008-2010 ASPAN Standards
1. “A Position Statement on Entry into Nursing Practice”
2. “A Position Statement on the Perianesthesia Patient with a Do-Not-Resuscitate Advance Directive”
3. “A Position Statement on Perianesthesia Advanced Practice Nursing”
4. “A Position Statement on Minimum Staffing in Phase I PACU”
5. “A Position Statement on Registered Nurse Utilization of Unlicensed Assistive Personnel (UAP)”
6. “A Position Statement on Fast Tracking”
7. “A Position Statement on On Call/Work Schedule”
a. “ASPAN Fatigue Evaluation Checklist”
8. “A Joint Position Statement on Intensive Care Unit Overflow Patients” developed by ASPAN, AACN, and ASA’s Anesthesia Care Team Committee and Committee on Critical Care Medicine and Trauma Medicine
9. “A Position Statement on the Nursing Shortage”
10. “A Position Statement for Medical-Surgical Overflow Patients in the PACU and ASU”
11. “A Position Statement on Visitation in Phase I Level of Care”
12. “A Position Statement on Safe Medication Administration”
13. “A Position Statement on Cultural Diversity and Sensitivity in Perianesthesia Nursing Practice”
14. “A Position Statement on Perianesthesia Safety”
15. “A Position Statement on the Geriatric Patient”
16. “A Position Statement on Advocacy”
VIII. COMPETENCY-BASED PRACTICE
A. Comprehensive guide to competency and skill development for the perianesthesia nurse
B. May be used to orient the new perianesthesia nurse
C. May be used for annual skills renewal and annual updates for the perianesthesia nurse
D. Provides the perianesthesia nurse a framework of essential performance criteria, thus establishing basic competencies needed to practice in diverse perianesthesia settings
E. Guidelines for using UAP in the perianesthesia setting
1. Value of using competent UAP in perianesthesia settings
2. Foremost concern is to promote a safe environment for the perianesthesia patient.
3. Perianesthesia nursing profession defines and supervises the education, training, and utilization of UAPs involved in direct patient care.
4. Perianesthesia RN is responsible for and accountable for the provision of nursing practice.
5. Perianesthesia RN supervises and determines appropriate utilization of any UAP involved in direct patient care.
6. Purpose of the UAP is to enable the professional perianesthesia nurse to provide nursing care for the patient.
F. Competencies for the RN
1. Mentoring
2. Critical thinking
3. Preanesthesia care
a. Preanesthesia testing
b. Preprocedural teaching
c. Preanesthesia history and assessment
d. Day of surgery preparation
4. Airway management
5. Circulation
6. Neurological
7. Renal
8. Moderate sedation and analgesia
9. Anesthesia agents and adjuncts
a. General inhalation agents
b. Muscle relaxants
c. Regional anesthesia
d. Intravenous agents
10. Perianesthesia fluid management and resuscitation
11. Pain and comfort management
12. Nausea and vomiting
13. Malignant hyperthermia
14. Thermoregulation
15. Age-specific competencies
16. Postoperative education and teaching
17. Medical imaging/interventional radiology
18. Documentation/legal
19. Transcultural nursing
20. EBP in the perianesthesia setting
G. Competency-based orientation for the UAP
1. Introduction
2. Patient rights, confidentiality, and communication skills
3. Basic infection, prevention, and control practices
4. Preoperative testing
5. Basic life support
6. Airway management
7. Care of the patient requiring monitoring
8. Care of the patient receiving intravenous fluids
9. Pain assessment and management
10. Care of the patient requiring comfort measures
11. Care of the patient with nausea and vomiting
12. Care of the patient requiring oral or nasal suctioning
13. Care of the patient requiring oral intake
14. Care of the patient with catheters and drains
15. Care of the patient with hypothermia
16. Care of the patient with malignant hyperthermia
17. Care of the patient with seizure disorder
18. Care of the patient requiring antiembolism devices
19. Assisting with ambulation
20. Safe transport of the perianesthesia patient
To obtain a copy of the 2008-2010 Standards of Perianesthesia Nursing Practice; A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting 2009; and/or A Competency Based Orientation and Credentialing Program for the Unlicensed Assistive Personnel in the Perianesthesia Setting 2007; contact ASPAN at 10 Melrose Avenue, Suite 110, Cherry Hill, NJ 08003; at 1-877-737-9696 (toll-free); or at www.aspan.org.
IX. ETHICAL ISSUES
A. Ethics
1. The science relating to moral action and moral values
2. Concerned with motives and attitudes and their relation to the good of the individual
B. Professional responsibilities and duties
1. Duty of veracity: a duty to tell the truth
2. Rule of confidentiality: a duty to control disclosure of personal information about patients to others
3. Health Insurance Portability and Accountability Act
a. Requires health care organizations to comply with federal regulations for privacy and electronic transactions
b. Portability standards
c. Accountability standards
d. Privacy standards
4. Duty of advocacy: nurse supports the best interests of the individual patient
5. Accountability: answerable to others for one’s actions
6. Duty of fidelity: obligation to be faithful to commitments to self and others
C. Ethical theories
1. Utilitarianism: defines “good” as happiness or pleasure
a. Greatest good for the greatest number of people
b. The end justifies the means
2. Deontology: system of ethical decision-making based on moral obligation or commitment to others
a. Emphasis on the dignity of human beings
3. Principalism: incorporates various existing ethical principles and attempts to resolve conflicts by applying one or more of them
D. Ethical principles
1. Beneficence: views the primary goal of health care as doing good for patients
2. Nonmaleficence: requirement that health care providers prevent or do no harm to their patients
3. Autonomy: freedom of action as chosen by an individual
4. Justice: duty to be fair to all people
E. Ethical decision-making: goal is to determine right from wrong in certain situations in which the lines are unclear.
1. Decision-making process
a. Obtain as much information as possible.
b. State the problem or dilemma as clearly as possible.
c. List all possible choices of action.
d. Evaluate the consequences of each choice.
e. Make a decision.
2. Moral model
a. Massage the dilemma.
b. Outline the options.
c. Resolve the dilemma.
d. Act by applying chosen option.
e. Look back and evaluate entire process.
F. Relationship of law and ethics
1. Legal system is founded on rules and regulations that are formal and binding; ethical values are subject to philosophical, moral, and individual interpretation.
2. Legal right may or may not be ethical.
3. Moral right may or may not be a legal right.
4. Law influences ethical decision-making, and ethics can influence legal decision-making.
G. “Perianesthesia Standards for Ethical Practice,” included in ASPAN’s 2008-2010 Standards of Perianesthesia Nursing Practice
H. ANA: Code of Ethics for Nurses With Interpretive Statements (nine provisions approved June 30, 2001)
1. The nurse practices with compassion and respect.
2. The nurse’s primary commitment is to the patient.
3. The nurse advocates for the health, safety, and rights of the patient.
4. The nurse is accountable for individual nursing practice.
5. The nurse owes the same duties to self as to others.
6. The nurse participates in maintaining and improving health care environments and conditions.
7. The nurse participates in the advancement of the profession.
8. The nurse collaborates with other health professionals.
9. The profession of nursing is responsible for articulating nursing values, for maintaining the integrity of the profession, and for shaping social policy.
I. The nursing shortage
1. The ANA, the National Council of State Boards of Nursing, and the National Federation of Licensed Practical Nursing, Inc: “Joint Statement on Maintaining Professional and Legal Standards During a Shortage of Nursing Personnel”
2. ASPAN: “A Position Statement on the Nursing Shortage”
BIBLIOGRAPHY
1. Agency for Healthcare Research and Quality, Clinical practice guideline: Acute pain management: Operative or medical procedures and trauma, AHCPR Publication No 92–00322. ( 1992)US Dept of Health and Human Services, Rockville, MD.
2. Agency for Healthcare Research and Quality, The patient care partnership. ( November 20, 2008) ; Available at:www.ahrq.org; Accessed.
3. American Hospital Association, The patient care partnership. ( February 10, 2008) ; Available at:www.aha.org/aha/issues/communicating-with-patients/ pt-carepartnership; Accessed.
4. American Nurses Association, Code for nurses with interpretive statements. ( 2001)American Nurses Publishing, Washington, DC.
5. American Nurses Association, Nursing: Scope and standards of practice. ( 2004)American Nurses Publishing, Washington, DC.
6. American Nurses Association, ANA position statements. ( February 10, 2008) ; Available at:www.nursingworld. org/mainmenucategories/healthcareand policyissues/anapositionstatements; Accessed.
7. American Society of PeriAnesthesia Nurses, 2008–2010 Standards of perianesthesia nursing practice. ( 2008)American Society of PeriAnesthesia Nurses, Cherry Hill, NJ.
8. American Society of PeriAnesthesia Nurses, A competency based orientation and credentialing program for unlicensed assistive personnel in the perianesthesia setting. ( 2007)American Society of PeriAnesthesia Nurses, Cherry Hill, NJ.
9. American Society of PeriAnesthesia Nurses, A competency based orientation and credentialing program for the registered nurse in the perianesthesia setting. ( 2009)American Society of PeriAnesthesia Nurses, Cherry Hill, NJ.
10. American Society of PeriAnesthesia Nurses, Position statements. ( February 10, 2008) ; Available at:www.aspan.org; Accessed.
11. Association of periOperative Registered Nurses, Standards, recommended practices, and guidelines. ( 2007)Association of periOperative Registered Nurses, Denver, CO.
12. Brent, N.J., Nurses and the law: A guide to principles and applications. ( 1997)WB Saunders, Philadelphia.
13. Brunsen, C.D.; Eichhorn, J.H., Risk management: Avoiding complications and litigation, In: (Editor: White, P.F.) Ambulatory anesthesia and surgery ( 1997)WB Saunders, Philadelphia.
14. Burden, N.; Quinn, D.; O’Brien, D.; et al., Ambulatory surgical nursing. ed 2 ( 2000)WB Saunders, Philadelphia.
15. Connelly, J., Emotions, ethics and decision making in primary care, J Clin Ethics 9 (3) ( 1998) 225–234.
16. D’Arcy, Y., Practice guidelines, standards, consensus statements, position papers: What they are, how they differ, American Nurse Today 2 (10) ( 2007) 23–24.
17. Follin, S.A., Nurse’s legal handbook. ed. 5 ( 2004)Lippincott Williams & Wilkins, Philadelphia.
18. Gastmans, C., Challenges to nursing values in a changing nursing environment, Nurs Ethics 5 (3) ( 1998) 236–245.
19. Gray, C., Understanding and complying with HIPAA, J Perianesth Nurs 18 (3) ( 2003) 182–185.
20. Green, C., Ethical issues in perianesthesia nursing, J Perianesth Nurs 15 (4) ( 2000) 229–236.
21. Gue, D.G.; Fox, S., Guide to medical privacy and HIPAA. ( 2002)Thompson Publications Group, Washington, DC.
22. Guido, G.W., Legal issues in nursing. ed 2 ( 1997)Appleton & Lange, Stamford, CT.
23. National Guideline Clearinghouse, Available at:www.guideline.gov/ ( November 20, 2008); Accessed.
24. Odom, J., Implementation of nursing standards, In: (Editor: Quinn, D.) Ambulatory surgical nursing core curriculum ( 1999)WB Saunders, Philadelphia.
25. Odom, J., Legal and ethical issues, In: (Editor: Quinn, D.) Ambulatory surgical nursing core curriculum ( 1999)WB Saunders, Philadelphia.
26. Redman, B.K.; Fry, S.T., Nurses’ ethical conflicts: What is really known about them?Nurs Ethics 7 (4) ( 2000) 360–366.
27. Saufl, N.M., Standards for ethical practice, In: (Editors: DeFazio Quinn, D.; Schick, L.) Perianesthesia nursing core curriculum: Preoperative, phase I and phase II PACU nursing ( 2004)WB Saunders, St Louis.
28. The HIPAA privacy, security, transaction, and code sets, and national resources, 1996. ( February 10, 2008) ; www.hipaadvisory.com; Accessed.
29. The Joint Commission, 2008 Hospital accreditation standards. ( 2008)The Joint Commission, Oakbrook Terrace, IL.
31. White, G., The code of ethics for nurses, Am J Nurs 101 (10) ( 2001) 73–75.
32. Wood, J., Ethical decision-making, J Perianesth Nurs 16 (1) ( 2001) 6–10.
33. Zickuhr, M.T., Nursing practice, nursing standards, and nursing practice, In: (Editor: Litwack, K.) Core curriculum for perianesthesia nursing practiceed 4 ( 1999)WB Saunders, Philadelphia.
