ADVANCE NURSING PRACTICE

TOPIC PRESENTATION
ON
NEUROLOGICAL ASSESSMENT

SUBMITTED TO: Ms. Phabita Philip

Lecturer

SUBMITTED BY: Ms. Ishara Adhikari

M.Sc (N) First Year

SUBMITTED ON: 25.07.2012

Dr. M.V.SHETTY COLLEGE OF NURSING

Nurses’ demands for increased professional recognition bring with them increased
responsibilities. While it is doctors who have 24-hour legal responsibility for the treatment of
patients, nurses are making more independent nursing decisions for which they are legally
accountable in a court of law, over and above their professional accountability for all their
actions.

In addition, patients are becoming more aware of their options to litigate if things go wrong
and know that they can sue individual professionals as well as trusts or other authorities.

AUTONOMY

DEFINITION
Autonomy refers to a person’s independence. It represents an agreement to respect
another’s right to determine a course of action.

Respect for another’s autonomy is fundamental to the practice of health care. It serves to
justify the inclusion of clients in all aspects of decision-making regarding their health care.

CHARACTERISTICS OF AUTONOMY
An autonomous person:-

 show responsibility for their own learning.

 show initiative.
 are able to monitor and evaluate their own learning.
 are reflective and show ‘high’levels of metacognition .
 are self-aware in relation to their own learning.
 are intrinsically motivated.
 are life-long learners.
 can manage and regulate their own learning.
 are adaptable and flexible in their approach to learning.

BARRIERS OF AUTONOMY

Internal Constraints
 The principle of autonomy affirms that individuals are permitted personal liberty to
determine their on actions.
 Of course not all persons are capable of autonomous choice and some , such as small
children or the severly retarded, have never had that capacity. These can be referred to as
internal constraints on autonomy. Other internal constraints are culture and religious
beliefs.

External Constraints

The main constraints perceived by ward sisters on their autonomy include the following.
 Nurse who are managing the wards are not free to take their own independent decisions.
They have to either follow doctor’s orders or the ward in-charge’s orders. In addition little
heed was paid to their views on patient care and ward management, innovation and
change proposed by the ward sisters.
 Innovative ideas were not encouraged or acted upon.
 They were obliged to work within narrow, ill-conceived guidelines on nursing practice
put together by nursing committees with no consultation at ward level. These barriers led
to lack of motivation and low morale, which affected their job satisfaction.

ACCOUNTABILITY
Accountability refers to the ability to answer for one’s own actions. The nurse balances
accountability to the client, the profession, the employer and society.
To remain accountable to society, nursing professionals agree to evaluate practices
and actions and to take action to preserve nursing excellence.
Accountability is best ensured and measured when quality of care has been defined.
The concept of accountability has two major attributes- answerability and responsibility.

Nursing personnel are accountable for:-

 providing safe and therapeutic environment for the patients.
 delivering component and personalized care.
 maintaining adequate supplies of material and equipment for smooth functioning
of the ward.
 maintaining accurate and up to date records and reports.
 maintaining good interpersonal relationships.
 protecting client’s legal rights and privacy.
 delivering care as per standards laid down by profession, statutory body and
institution.

ASSERTIVENESS

DEFINITION
 Assertiveness is a tool for expressing ourselves confidently and a way of saying ‘yes’ and
‘no’ in an appropriate way.
It is considered as health behaviour for all people against personal powerlessness and
results in personal empowerment.
Assertiveness is a style of behaviour to interact with people while standing up for your rights.

BENEFITS

 Creates healthy and meaningful relationship.

 There is less friction and conflicts.
 There is increased self respect as well as respect from others.
 Productivity at work and at home increases.
 There is less stress at work and overall sense of well-being.

As nurses work in different situations they have to be assertive in order to meet the
challenges and to win the cooperation from others.

CHARACTERISTICS OF ASSERTIVENESS

 Assertiveness involves interpersonal behaviours that permit people to defend and

maintain their legitimate rights in a respectful manner that does not violate the rights
of others.
 Assertive communication is honest and direct.
 Assertive communication accurately expresses the person’s feelings, beliefs, ideas and
opinions.
 Respect for self and others constitutes the basis for assertive communication.
 Assertiveness always implies that the individual has the choice to voice an opinion as
well as not to say anything at all.
 One of the keys to assertive communication is that the individual is in control of the
communication and not merely reacting to another’s emotions.

HOW TO BECOME ASSERTIVE ?

Assessing Self Assertiveness

Answer the following questions to assess your self assertiveness:-

 Who am I and what do I want ?
 Do I believe I have the right to want it ?
 How do I get it ?
 Do I believe I can get it ?
 Have I tried to be assertive with a person I am having difficulty communicating with ?
 Am I letting my fears and perceptions cloud my interactions ?
 What is the worst that can happen if we communicate ?
 How does it feel to be in constant fear of alienation or rejection ?
Rules For Assertiveness

The rules for developing an assertive communication style and assertiveness:-

  It is a learned skill.
 It takes practice.
 It requires a desire and motivation to change.
 It requires a willingness to make mistakes and try again.
 It requires an understanding that not every outcome sought will be obtained.
 It requires strong self-esteem.
 Listening to self is necessary for identifying needs.
 Others should be allowed to make mistakes.
 To act in a way that promotes your dignity and self-respect.
 To be treated with respect.
 To experience and express your thoughts and feelings.
 To slow down and make conscious decisions before you act.
 To ask for what you want.
 To say “NO”.
 To change your mind.
 To feel important and good about yourself.
 To be treated as an individual with special values, skills and needs.
 To make decisions regarding your life.
 To recognize that your needs are as important as others.

VISIBILITY OF NURSES

Definition

Visibility of nurses can be simply defined as the image of a nurse. Muriel Richard identifies 3
heritages from past that inhibit the progress of nursing:-

i. The Folk Image Of Nurse

 The ancient times women carried major responsibility in families.
 Suppression and black magic played major role in the treatment rendered and
there was a close relationship between religious and healing writs.

ii. The Religious Image Of Nurse

 In Christian era, groups were organised who took care of the sick, the poor, the
orphans, widows, slaves and prisoners in the name of charity.
 It is assumed that in early civilization, there were people in meeting the needs
of the sick.
 Both men and women got equal opportunity and unmarried women had
opportunity for service.

iii. The Servant Image Of Nursing

 During the renaissance period (10-14 century) which is also known as ‘Age of
Discovery’, nursing was considered as a domestic service. Nurses worked as
servants, where pay was poor and work was strenuous.

The nightingale influence in the field of service brought a change in the image of
nurses. During that period nurses were considered as a symbol of goodness.
 iv. Doctor’s Handmaidens
In the 19th century, nursing was considered to have no other purpose than to
serve the physician and not the patient.
Nurses were viewed as someone with no knowledge of her own and who borrows
doctor’s knowledge still and act as his agent.

LEGAL CONSIDERATIONS IN NURSING

Legal Issues In Speciality Practice Areas

Maternal And Infant Nursing

The common lawsuits against nurses will include the following:-

i. Problems of medication- Nurses are authorised to administration of medication.

Some of the common problems occurring during medication administration are:
- improper client identification
- wrong dosage of medication, route or time.
- failure to monitor side-effects.

ii. Failure in adequate client monitoring- Nurses are expected to monitor their clients
at appropriate time intervals that depend upon the client’s condition. Labour and
delivery pose a unique monitoring challenge, in that there are two clients to monitor-
the mother and the baby.

iii. Failure to adequately assess the client- The nurse is an important member of the
health care team who is with the client constantly, and responsible for the minute by
minute evaluation of the client progress.

iv. Failure to report changes in the patient- Whenever the nurses assessment indicates
that the client’s condition has changed, the nurse must notify the physician. Nurses
must understand that failing to notify a doctor of a problem often leads to a delay in
appropriate medical care being implemented. This in turn can lead to an injury to the
client and lawsuit.

v. Abortions- Nurses cannot be forced to participate in procedures they find morally

offensive. Nurses have the right to refuse to assist with abortions. She can assist with
abortion if it is performed under MTP act.

vi. Nursing care of newborn- There are certain legal requirements in providing nursing
care for newborns such as properly identifying the infant-mother pair as soon as
possible with finger prints, foot prints and wrist bands or obtaining blood samples.

Pediatric Nursing

i. Pediatric nurses are responsible for preventing children in their care from
accidentally harming themselves.
 ii. All poisonous substances and sharp objects should be kept out of the reach of
children.
iii. Children should be kept under constant surveillance to minimize oppurtunities for
accidental harm.

Medical-Surgical Nursing
Some common acts of negligence in medical-surgical nursing are as follows:

i. Overlooked sponges, instruments needles- In the operation theatre, it is the

responsibility of the nurse to count the sponges, instruments, needles before the
closure of the abdomen or any cavity.

ii. Falls- The nurse could be liable if a patient falls from the bed or due to improper
securing of patient on examination table or improper application of restraints.

iii. Injury- Injury due to the use of defective apparatus or supplies can cause the nurse to
be held liable.

iv. Assault and Battery- Failure to take the informed consent of the patient prior to any
procedure, treatment, investigation, the nurse can be held liable.

v. Maintenance of records and reports- Failure to maintain accurate record and report
or removing a position of record may also make the nurse liable.

Psychiatric Nursing

The practice of psychiatric nursing is influenced influenced by law, particularly in

concern for the right of patients and the quality of care they are receiving. In psychiatric
setting, the process of hospitalization can be traumatic. At present 3 major types of admission
are used i.e., informal, voluntary and involuntary.

i. Informal admission- This type of admission to the psychiatric hospital occurs

in the same way as a person is admitted to a general hospital i.e., without
formal application. The individual is then free to leave any time. The patient is
often requested to sign on an agreement of medical advice, but is not
compelled to do so.

ii. Voluntary Admission- Under this procedure, any citizen of lawful age may
apply in writing for admission to a public or private psychiatric hospital. He
agrees to receive treatment and abide by the hospital rules. His reason for
admission may be his own personal decision or may be based on the advice of
family or a health professional.

iii. Involuntary admission- Involuntary admission do not always imply

compulsion. It means that the request for hospitalisation did not originate with
the patient and may signify that either it was actively opposed by him or he
was indecisive and did not resist.
 iv. Immediate restraint of the insane- If an insane person is dangerous to
himself or to others or if he is likely to injure his property or others, he can be
lawfully admitted to a mental hospital.

v. Reception order on petition- The family members of the patient have to

submit petition for a reception order for admission. The petitioner must have
attained the age of majority and must have seen the patient within 14 days of
making petition. The petition has to be supported by two medical certificates
obtained from a government gazetted medical officer.
The magistrate personally examines and makes reception order after
obtaining consent from the superintendent of the mental hospital.

vi. Reception of criminal lunatics- On the order of the presiding officer or a

court, criminal lunatics have to be admitted into a mental hospital.

vii. Abscond of the patient- When a patient absconds from the ward, inform
immediately to the nursing officer, hospital superintendent, local police station
and his relatives.

Legal Safeguards In Nursing Practice

I. Licensure

All nurses who are in nursing practice have to possess a valid licensure, issued by the
respective state nursing council. He/She is being in possession of license to practice
which is his/ her sole authority.

II. Good Samaritan Laws

Most state governments enacted ‘Good Samaritan Laws’ that exempt doctors and
nurses from liability when they render first aid during emergency. These laws limit
liability and offer legal immunity for people helping in an emergency.

III. Good Rapport

Developing good rapport with the client is very important to prevent malpractice. A
lawsuit is often circumvented when the nursing staffs treats the client with warrants
and caring.

IV. Standards Of Care

All professionals practicing in the medical field are held to certain standards when
administering care. Standards of care come from different sources including laws,
organisational standards and institutional policies and procedures. It is always better
to follow standards of care to avoid malpractice and do not attempt anything beyond
the level of competence.

V. Contracts
 A contract is a written or oral agreement between two people in which goods or
services are exchanged. Treating a patient without obtaining proper consent can lead
to a charge of assault or battery.
Professional nurses seek always to ensure informed consent, client’s rights and full
communication and the consent should be taken in written form specified by the
respective institution or government.

LEGAL RESPONSIBILITIES OF NURSE

I. Responsibility Of Appointing and Assigning

The nurse administrators have responsibility for staffing and supervising nursing units
to ensure safe, effective patient care. Therefore they have the authority to temporarily
reassign a nursing employee from one unit to another, to compensate for emergency
staff shortages.

II. Responsibility In Quality Control

The nursing administrator and the authority of the agency at all levels have a legal
obligation to ensure nursing care quality. A nurse manager’s legal responsibility for
quality control of nursing service imposes a duty to observe, report and correct the
incompetence of any patient care provider.

III. Responsibility For Equipment

To protect patients and employees from injury, a nurse manager must ensure that all
patient care equipments are fully functional and that defective equipment is promptly
repaired or replaced. Nurse have the duty to refuse to use equipment known to be
faulty or that was not designed for use in the situation where it was ordered.

IV. Responsibility for Observation And Reporting

The nurse has a duty to record and report observations of a patient’s condition
promptly so that the physician can base treatment, decisions on up-to-date information
about the patient’s health needs.

V. Responsibility To Protect Public

The nurse has the legal duty to protect the public from communicable diseases and
also to alert the public against any epidemic outbreak.

VI. Responsibility For Record Keeping and Reporting

Nurses have legal responsibility for accurately reporting and recording patient’s
conditions, treatments and responses to care. The medical record is a written or
 computerised account of a patient’s illness and treatment that includes information
submitted by all members of the patient’s health care team.

LEGAL ROLES OF NURSES

Nurses have three separate, interdependent legal roles each with rights and associated
responsibilities:-

I. Provider of Service- The nurse is expected to provide safe and competent care.
Responsibilities are:-
 To provide safe and competent care.
 To inform clients of the consequences of various alternatives and outcomes of
care.
 To provide adequate supervision and evaluation of others for whom the nurse
is responsible.

II. Employee or Contractor of Service- A nurse who is employed by an agency works

as representative of the agency. Responsibilities are:-
 To fulfil the obligations of contracted service with the employer.
 To respect the employer.
 To respect the rights and responsibilities of other health care providers.

III. Citizen
As a citizen the responsibility of the client is to protect the recipients of care.

CONCLUSION

In a nutshell, autonomy, accountability and assertiveness are the qualities that a nurse
should have to provide health care services efficiently.
Professional nurse autonomy is the belief in the centrality of the client when making
responsible decisions that reflect the advocacy for the client.
Accountability means a nurse is answerable for her actions and have obligation to act.
Assertiveness is a style of behaviour to interact with people while standing up for
your rights.
Also it is essential for a nurse to have knowledge regarding her legal rights, duties and
responsibilities to safeguard the patients and herself.

BIBLIOGRAPHY
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Websites:-

1) www.ncbi.nlm.nih.gov/pmc/articles.
2) www.nursingtimes.net/nursing-practice-clinical-research.
3) www.nmc.uk.org/nurses-and-midwives/advocacy-and-autonomy.