As nurses, we deal with informed consent a lot
—on admission to a hospital/clinic or before a procedure/surgery. Nurses typically are assigned the task of obtaining and witnessing written consent for healthcare treatment. I’ll never forget admitting to our busy psychiatric unit a young mother who’d been found unresponsive after a drug overdose. She’d been taken to the emergency room to stabilize, and her young child taken into protective custody. Now on the locked psych unit, she was terrified to sign the consent form for admission and treatment, afraid for herself and her child whose whereabouts she did not know. I repeatedly explained what I knew about her child, treatment plan, and consent process, including that she did not have to sign the admission consent. However, if she did not sign, her admitting psychiatrist would request, and be granted, a “court hold” to admit her involuntarily. If she signed as a “voluntary” admission, it would suggest she was cooperating with treatment.
I knew it was in her best interest to sign, but understood it was her
decision. The goal of informed consent is to assure patient autonomy
. My patient didn’t have a choice of treatment alternatives, but she did have a choice to be admitted voluntarily or involuntarily. I felt ethically compelled to preserve that choice.
After almost an hour of listening, supporting, and explaining, I needed to give medications to other patients. My plan was to offer this woman a hot shower to help calm her and give time to process what was happening. Then, if she still could not sign the consent, I would explain I had to inform her psychiatrist, and we would proceed with a court hold.
When I stepped out of the room, I told my supervisor my plan. She hastily went to the patient, stuck the form and a pen in front of her, saying, you need to sign this NOW!
My patient complied, tears streaming down her face.
I’ve since thought a lot about informed consent. I’ve worked in med-surg, cardiac rehab, intensive care, medical research, and psychiatry. In all settings, nurses are on the front lines of assuring patients truly are giving informed
What is involved in informed consent?
, this requires that the patient, or his/her surrogate, is informed of the risks, benefits, and alternatives to a treatment. A signature on the consent form provides legal documentation of consent.
, consent is about patient autonomy,
meaning the patient understands and freely agrees to the treatment.
Consent may be withdrawn at any time. Healthcare providers must accept and support refusal or withdrawal of consent even if they disagree with the patient.
The consent process can be affected by complexity of the treatment, patient condition and ability to understand information, and if treatment is emergent or elective.
What can nurses do to improve informed consent?
Think about consent as a process
to assure patient understanding and agreement, not just signing a form.
Informed consent should be a collaborative activity
between the physician, nurse, and patient. The physician should have obtained consent before the nurse has the patient sign a form.
Nurses can offer what we do best—patient teaching,
as we check patient understanding and obtain written consent. Where possible, use the teach-back method, asking the patient to repeat back what he/she understands. However, our teaching cannot take the place of prior physician / patient shared decision-making.
Assess for paternalism
– from the physician, from yourself. We understand so much more than the patient and are trying to help, but we cannot pressure or tell a patient what to do.
Consenting to treatment is scary. As much as possible, obtain consent in a quiet and calm setting
, with time to answer questions.
What about informed consent for nursing interventions?
Although we normally don’t obtain written consent for nursing interventions, such as holistic care using mind-body practices or spiritual therapeutics, we still must assure patients’ informed consent.
A critical topic we discuss frequently in Journal of Christian Nursing
is spiritual care. How do we assess for spiritual needs and appropriately respond? What ethical guidelines must be followed when offering spiritual care? A comprehensive article discussing informed, ethical, and non-coercive spiritual care that could be applied to other holistic nursing interventions is, “Spiritual Care: Evangelism at the Bedside?,”
by nurse researcher and spiritual care expert, Elizabeth Johnston Taylor. Take a look at this free
article and discover principles for ethical nursing interventions.
This Nurses Week, remember that informed consent is a way of nursing
each of us needs to live out as we offer our patients ethical practice and quality nursing care!
Barry, M. J. (2012). Shared decision making: Informing and involving patients to do the right thing in health care
. Journal of Ambulatory Care Management, 35(
2), 90 – 98.
Cook, W. E. (2014). “Sign here:" Nursing value and the process of informed consent
Plastic Surgical Nursing, 34
Menendez, J. B. (2013). Informed consent: Essential legal and ethical principles for nurses. JONA's Healthcare Law, Ethics, and Regulation, 15
Kathy Schoonover-Shoffner, PhD, RN
Editor, Journal of Christian Nursing
A few weeks ago my husband was in the emergency room with a broken rib, which resulted from a fall. His nurse was very attentive to his need for pain management. He had never had morphine before and after his second dose, he asked the nurse “How much of this will you give me?” Her reply was, “As much as it takes to safely control your pain.” What a great answer!
It isn’t always this easy when it comes to pain management. I’ve shared a story previously about a patient in our ICU, whose family member, who happened to be a nurse himself, wouldn’t allow us to treat his sister’s pain. It was a challenging case
, and ultimately, our hospital’s ethics committee was consulted.
The position of the American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA) is “that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management.” As nurses, we have a responsibility to make ethically sound decisions when it comes to pain management. But, how do we do this?
Be familiar with related ethical standards
- Beneficence is the duty to do what's good for the patient while considering his or her wishes. Nonmaleficence is the duty not to harm patients. The challenge here is to achieve pain control while ensuring patient safety.
- Justice refers to fair treatment for all. This can be tricky because pain can't be measured objectively and we must rely on a patient’s self-report.
- Autonomy requires us to respect, support, and advocate for patients, even when it goes against our own beliefs.
Be aware of barriers to effective pain management
- Sometimes patients aren’t able to communicate about their pain. Whether the patient is non-communicative, there is a language barrier, or the patient finds it difficult to describe the pain they are experiencing, use your knowledge and skills to perform a thorough history and physical assessment.
- Time constraints can get in the way of assessing and managing a patient’s pain. Do your best to actively listen to the patient, plan, and collaborate with other team members.
- Sometimes cost is an issue and certain modalities aren’t covered by a patient’s insurance. If this is not in your realm of knowledge, consult with a colleague who is familiar with the financial aspects of pain management.
Set goals and make a pain management plan
- Assess your own beliefs and think about your past experiences.
- Remember that every patient is unique.
- Tailor your patient and family education appropriately.
- Encourage patients to become active partners in controlling their pain. Remind them that pain control aids recovery.
- Actively listen to the patient’s self-report of pain.
- Be alert to fears related to reporting pain. For example, patients might not report pain for fear of having to undergo more procedures.
- Consider asking about burning, aching, tightness, discomfort, or throbbing. Research shows that to minimize their pain, elders may not use the word ‘pain.’
- Take cultural differences into account.
- Use pain scales that are appropriate for the patient.
- Ask the patient what level of pain would be satisfactory.
- Explain the difference between pain elimination and pain control; completely eliminating pain while maintaining safety is not always realistic.
- Work with the patient to set ‘functional goals’ – for example, being able to walk down the hall and back.
- Consider non-pharmacologic methods, such as lighting, positioning, distraction techniques (music, guided imagery), relaxation techniques (breathing, progressive muscle relaxation), and advanced complementary modalities (massage, biofeedback).
- Monitor the patient for medication adverse reactions, contraindications, and interactions.
As nurses, we are well-positioned and obligated to advocate for safe pain management. Remember to listen, collaborate, plan, and evaluate!
Diallo, B., & Kautx, D. (2014). Better Pain Management for Elders in the Intensive Care Unit
. Dimensions of Critical Care Nursing
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., . . . Turner, H. (2012). American Society for Pain Management Nursing Position Statement: Pain Management in Patients With Substance Use Disorders
. Journal of Addictions Nursing
Quinlan-Colwell, A. (2013). Making an Ethical Plan for Treating Patients in Pain
Lisa Bonsall, MSN, RN, CRNP
In 1859, Charles Dickens wrote the book, "The Tale of Two Cities," which was a comparison of life in London and Paris and compared life of the aristocracy versus life of the peasantry in those two cities. Throughout my 30 plus years of being a nurse and nurse practitioner, I have watched and participated in the ethical dilemmas nurses and other healthcare providers encounter on a day to day basis. I have spent the majority of my professional nursing career in acute and critical care. As a nurse practitioner, my role is different than when I was a nurse; however, the issues I face are the same as all nurses in regards to ensuring patients receive optimum care that improves quality of life, not necessarily extending it. This brings me to, "The Tale of Two Patients."
A few weeks ago I took care of two patients; two patients with similar stories, both had end-stage COPD and both were admitted to the ICU for a COPD exacerbation. Both patients received similar treatment, and both patients continued to deteriorate simply because their disease had progressed beyond recovery. As a nurse, I was always taught to focus on quality not quantity of life, and quality of life is defined by the patient, not the healthcare professionals or the family.
The first patient had an advanced directive and had obviously communicated well with her family. They were all in agreement the patient should not be intubated, and instead, be placed on hospice and made comfortable. There was great peace among the patient, her family members and the entire nursing and healthcare staff. They rejoiced in the fact the patient had lived a full life and could now go on to a better place to be with her husband who had passed two years prior. Everyone agreed -- following the patient's advanced directive and making her a do not resuscitate was the right thing to do.
The second patient did not have an advanced directive, and had never spoken to her family about her wishes. Despite numerous attempts to discuss the patient's prognosis with the patient and her family, the family insisted everything be done and the patient capitulated to their demands. The patient was intubated and placed on a ventilator. Everyone knew the patient would never come off the vent and would eventually die in the ICU. After several days, the patient went into multiorgan failure and the family finally agreed that the patient should be allowed to die in peace. The patient was placed on a morphine infusion for comfort and died with the family still fighting over her. There was great sorrow in the eyes and hearts of everyone taking care of her. Nurses are about quality care, and even though the patient eventually died comfortably, everyone knew the situation could have been avoided if the patient had discussed her wishes with her family and her primary care provider and had an advanced directive.
As nurses, we see the ethical importance of doing what our patient's want; we are their advocates and their voice even in their most desperate hour. Healthcare professionals have an obligation to speak with their patients before the patient is in a life-threatening situation. The first time a discussion occurs should not be when the patient is critically ill and facing no chance of recovery. Quality of life must be defined by the patient and no one else. In this day and age, the tale of two patients should not be a story we tell in healthcare.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
Health, Learning & Practice
Nurse Practitioner, Critical Care Services
Penn Medicine Chester County Hospital
College of Nursing & Health Sciences
We face ethical issues and make related decisions – or help others to do so – every day. As we focus on nursing ethics for National Nurses Week, we will be bringing you daily blog posts related to nursing ethics. We have some guest blog authors lined up to cover ethical topics important to nurses, including informed consent, advance directives, moral distress, horizontal violence, pain management, elder abuse, and end-of-life issues
. We hope that you’ll join this important conversation with us. Have a great week everyone!
- A Tale of Two Patients - Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
- Ouch! Safely keeping patients pain-free - Lisa Bonsall, MSN, RN, CRNP
- Informed Consent: An Ethical Way of Nursing - Kathy Schoonover-Shoffner, PhD, RN
- An Ethical Perspective on Elder Abuse - Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
- Moral Distress - Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
- End-of-Life in Acute Care - William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN
- Banishing the Bully Among Us - Maureen Shawn Kennedy, MA, RN, FAAN
Last week, we asked nurses on Facebook
, and Google+
to share words that describe nurses and what we do. Here's the result! Any more to add?
National Nurses Week runs from May 6 through May 12, ending on Florence Nightingale’s birthday. Every year, NursingCenter hosts a variety of celebrations, ranging from discounts on continuing education activities, journal articles, and nursing eBooks, to special giveaways, blog posts, and more.
This year, the American Nurses Association has given National Nurses Week the theme, “Ethical Practice, Quality Care,” and we are gearing up to bring you the same great week of celebrations as a special thank you to all of our members.
• Be sure to check our National Nurses Week page each day that week for discounts, activities, and blog posts.
• We will be developing an exciting CE Collection around topics dealing with “Ethical Practice, Quality Care.”
• Don’t forget to register for any of our free nursing newsletters, as we will be gifting a variety of offers to our newsletter members.
• As a bonus, there are two Lippincott conferences running during National Nurses Week this year, the National Conference for Nurse Practitioners and the Lippincott Clinical Nursing Conference. Both nursing conferences are being held in Philadelphia.
Stay tuned for more information on how to celebrate National Nurses Week with NursingCenter.
The salary gap, in general, is upsetting. For some reason, I just didn’t expect it to exist in nursing. In a profession that is predominantly female (according to a 2011 census report, only 9.6% of nurses are male), it really never occurred to me that such a discrepancy in pay was realistic. The results of recent research published in the Journal of the American Medical Association demonstrate that pay inequality not only exists in nursing, but is quite significant.
Here are some highlights from the research letter, which looked at two large data sets (the National Sample Survey of Registered Nurses [1988 to 2008] and the American Community Survey [2001 to 2013]) to assess salary trends by gender:
- Male RN salaries were higher than female RN salaries every year, with an overall annual difference of $5,148.
- In ambulatory care, the salary gap was $7,678; in hospitals, it was $3,873.
- With the exception of orthopedics, male nurses out-earned female nurses in every specialty with the gap ranging from $3,792 in chronic care to $17,290 for nurse anesthetists.
Like many others, I find these results discouraging. However, I am hopeful that nurses will be encouraged to speak up about our worth and engage in salary negotiations. I also am hopeful that employers will recognize these inequities and examine their pay structures.
What’s missing in this research is the reason for this gap in pay. Care to share your thoughts on this?
“Nursing has been a blessing to me and my family that has allowed me to travel the globe and care for the sickest of the sick across the lifespan.” Scott DeBoer RN, MSN, CPEN, CEN, CCRN, CFRN is a nurse leader with more than 20 years of experience. Currently, he serves as a flight nurse for the University of Chicago Hospitals. He is also a founder of Peds-R-Us Medical Education, a seminar company interested in enhancing the care of children.
DeBoer wrote the Certified Pediatric Emergency Nurse Review book, which is now in its third edition, as well a body piercing removal handbook, and a book on emergency care for newborns. He earned his master's degree in critical care nursing from Purdue University in 1996 and spent time there as a clinical nursing instructor.
As our next Nurse On the Move, DeBoer is eager to promote the nursing profession and offer his views on nursing education, pediatric care, and the future of nursing.
Q: Why did you choose nursing as a profession?
A: I grew up thinking I was going to be a pediatrician, however, after several orthopedic injuries in high school and way too much time spent in the ER, I learned to love the nurses and not be so enthralled with the physicians. Nursing has been an absolutely amazing career.
Q: What attracted you to the career of a flight nurse?
A: Very early in my career, the flight team picked up a 3-month old child in status epilepticus from our ER. I was freaking out to say the least, as I’d never given Valium to anyone that small in my life. The flight crew was nothing short of amazing; I knew from that point on that flight/transport nursing was what I wanted to do as a career.
Q: How important is it for nurses to continue their education?
A: I would say education is crucial, especially for nurses just entering the profession. A bachelor's degree is essential. I work with many incredibly skilled paramedics who obtained their associate's degree in nursing from local community colleges, however, they can't get nursing jobs as many hospitals won't even interview without a bachelor's degree.
Q: Why is pediatric emergency care important to you?
A: Simply, I don't really like taking care of big people. If have a choice, I prefer taking care of sick kids – kids are amazing. They tend to get really sick, really fast, which of course can be scary, but, when they get better, they get better really fast as well. They haven't had years of bad habits (Burger King, beer, etc.) to result in their illness or injuries. They're good kids who’ve bad things happen to them. I just try to help them (and their families) get better.
Q: For a nurse starting out, what would be your number one piece of advice?
A: Beyond getting your bachelor's, it's not being afraid to ask questions of experienced nurses on the unit. The idea that there is no stupid question, especially when it applies to patient care, is really true. What you learned in school is a very, very small part of what you learn on the job from everyone from housekeeping and unit secretaries (they are truly invaluable) to the chief of surgery. Everyone has something they are an expert at and most times are willing (and happy) to teach, if asked by those honestly desiring to learn.
Q: What do you see as a major obstacle/problem in the current nursing environment?
A: The electronic medical record epidemic – they aren’t going anywhere. I know this and have resigned myself to this fact, however, I truly miss the ability to sit on the patient's bed, look them in the eye, and get a quick history. In many facilities, I have to look at a computer screen bolted to the wall while trying to talk to the patient or their family in another part of the room. This is not ideal – the focus needs to be on the patient and their family, not on clicking computer keys.
Q: What do you envision for the future of nursing?
A: I envision an ongoing advancement in the roles of advanced practice nurses, especially with continued financial considerations and changes in healthcare reimbursement. On the transport medicine side, more patients will be transported by ambulance versus helicopters, and emergency departments will continue to see more patients, as access to primary care practitioners remains an issue.
*Do you know an inspiring nurse to be featured for the next Nurse On the Move? Email your submissions to ClinicalEditor@NursingCenter.com.
If you are administering I.V. fluids or medications to a patient through a peripheral I.V. site, be alert for signs and symptoms of complications, institute preventive measures, and know how to intervene when complications do occur.
Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue. Infiltration can be caused by improper placement or dislodgment of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel lumen.
Signs and symptoms
- Swelling, discomfort, burning, and/or tightness
- Cool skin and blanching
- Decreased or stopped flow rate
- Select an appropriate I.V. site, avoiding areas of flexion.
- Use proper venipuncture technique.
- Follow your facility policy for securing the I.V. catheter.
- Observe the I.V. site frequently.
- Advise the patient to report any swelling or tenderness at the I.V. site.
- Stop the infusion and remove the device.
- Elevate the limb to increase patient comfort; a warm compress may be applied.
- Check the patient's pulse and capillary refill time.
- Perform venipuncture in a different location and restart the infusion, as ordered.
- Check the site frequently.
- Document your findings and interventions performed.
Extravasation is the leaking of vesicant drugs into surrounding tissue. Extravasation can cause severe local tissue damage, possibly leading to delayed healing, infection, tissue necrosis, disfigurement, loss of function, and even amputation.
Signs and symptoms
- Blanching, burning, or discomfort at the I.V. site
- Cool skin around the I.V. site
- Swelling at or above the I.V. site
- Blistering and/or skin sloughing
- Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.
- Be aware of vesicant medications, such as certain antineoplastic drugs (doxorubicin, vinblastine, and vincristine), and hydroxyzine, promethazine, digoxin, and dopamine.
- Follow your facility policy regarding vesicant administration via a peripheral I.V.; some institutions require that vesicants are administered via a central venous access device only.
- Give vesicants last when multiple drugs are ordered.
- Strictly adhere to proper administration techniques.
- Stop the I.V. flow and remove the I.V. line, unless the catheter should remain in place to administer the antidote.
- Estimate the amount of extravasated solution and notify the prescriber.
- Administer the appropriate antidote according to your facility's protocol.
- Elevate the extremity.
- Perform frequent assessments of sensation, motor function, and circulation of the affected extremity.
- Record the extravasation site, your patient's symptoms, the estimated amount of extravasated solution, and the treatment.
- Follow the manufacturer's recommendations to apply either cold or warm compresses to the affected area.
Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result of vein trauma during insertion, use of an inappropriate I.V. catheter size for the vein, or prolonged use of the same I.V. site.
Signs and symptoms
- Redness or tenderness at the site of the tip of the catheter or along the path of the vein
- Puffy area over the vein
- Warmth around the insertion site
- Use proper venipuncture technique.
- Use a trusted drug reference or consult with the pharmacist for instructions on drug dilution, when necessary.
- Monitor administration rates and inspect the I.V. site frequently.
- Change the infusion site according to your facility's policy.
- Stop the infusion at the first sign of redness or pain.
- Apply warm, moist compresses to the area.
- Document your patient's condition and interventions.
- If indicated, insert a new catheter at a different site, preferably on the opposite arm, using a larger vein or a smaller device and restart the infusion.
An immediate, severe hypersensitivity reaction can be life-threatening, so prompt recognition and treatment are imperative.
Signs and Symptoms
- Sudden fever
- Joint swelling
- Rash and urticaria
- Ask the patent about personal and family history of allergies.
- For infants younger than 3 months, ask the mother about her allergy history because maternal antibodies may still be present.
- Stay with the patient for five to 10 minutes to detect early signs and symptoms of hypersensitivity.
- If the patient is receiving the drug for the first or second time, check him every five to 10 minutes or according to your facility's policy.
- Discontinue the infusion and notify the prescriber immediately.
- Administer medications as ordered.
- Monitor the patient's vital signs and provide emotional support.
Local or systemicinfection is another potential complication of I.V. therapy.
Signs and symptoms
- Redness and discharge at the I.V. site
- Elevated temperature
- Perform hand hygiene, don gloves, and use aseptic technique during I.V. insertion.
- Clean the site with approved skin antiseptic before inserting I.V. catheter.
- Ensure careful hand hygiene before any contact with the infusion system or the patient.
- Clean injection ports before each use.
- Follow your institution’s policy for dressing changes and changing of the solution and administration set.
- Stop the infusion and notify the prescriber.
- Remove the device, and culture the site and catheter as ordered.
- Administer medications as prescribed.
- Monitor the patient's vital signs.
With careful attention and skill, you’ll be able to recognize, prevent, and manage these complications of peripheral I.V. therapy.
(2008). I.V. Essentials: Complications of Peripheral I.V. Therapy. Nursing Made Incredibly Easy!, 6 (1).
Smeltzer, S. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing, 12e. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Spencer, S. & Gilliam, P. (2015). Teaching patients about their short peripheral I.V. catheters. Nursing2015, 45 (2).
Vacca, V. (2013). TIME CRITICAL: Vesicant extravasation. Nursing2013, 43(9).
Posted: 2/9/2015 6:59:20 PM
Lisa Bonsall, MSN, RN, CRNP
| with 2 comments
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Categories: Patient Safety
Posted: 2/6/2015 8:26:22 PM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
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Categories: Education & Career