As a pediatric hematology registered nurse (RN) practicing in the state of Ohio I am licensed through the Ohio Board of Nursing (2013). The Ohio Board of Nursing determines licensure criteria by relying those established by national certifying organizations and in Ohio this is the National Council of State Boards of Nursing. The scope of practice for RNs in Ohio is determined by Chapter 4723 of the Ohio Revised Code (ORC), in addition to the administrative rules developed under this Chapter (Ohio Board of Nursing, 2011).
Scope of Practice Considerations
Under Chapter 4723 ORC an RN is authorized to evaluate a patient's health, develop a nursing regimen to restore health, prevent disease, and promote health, provide health counseling and teaching, and under the authorization of a doctor or nurse practitioner (NP) administer medications, treatments, and otherwise implement the nursing regimen. Based on the American Nurses Association (ANA) the scope of practice is assessment, diagnosis, planning, implementation, outcomes identification, and evaluation (Fowler, 2008). The scope of practice defined for RNs by the Ohio laws and rules, and by the ANA, are effectively the same.
In 2010, the Oncology Nursing Certification Corporation began offering an examination for becoming a Certified Pediatric Hematology/Oncology Nurse (Hennessy, 2009). Ohio is one of several states that approved the continuing nursing education required for CPHON certification (ONCC, 2012). The nine categories covered by the 120-item CPHON certification test are psychosocial dimensions of care, disease related biology, treatment, supportive care, pediatric oncologic and hematologic emergencies, long-term follow-up and survivorship, health maintenance, end of life care, and professional performance. This is a much more detailed and exhaustive list of the roles that a pediatric hematology RN may be required to perform. All the duties and roles that I've been expected to perform in my practice fit within this list.
Professional Practice Development: Ethics
The professional performance category on the CPHON certification exam provides a detailed list of professional development goals, including ethics, cultural competence, teaching, professional boundaries, risk management, evidence-based practice, and self-care (ONCC, 2012). The ANA standards of professional performance are very similar (Fowler, 2008); however, Chapter 4723-4 ORC does not include a specific statement on ethics (Ohio Board of Nursing, 2013).
Despite the lack of the word 'ethics' in Ohio law covering nursing, Chapter 4723-4-03 OCR nevertheless addresses ethical issues that impact nursing care standards (Ohio Board of Nursing, 2013). An RN is expected to stay current on how best to perform their duties so that patient and provider safety is ensured. In addition, a nursing professional is expected to provide consistent care and be able to handle complications. When care requires special knowledge and/or skills, the nursing professional should obtain these skills and knowledge from a reputable educational institution or be able to document and/or demonstrate competence. This general outline defines the professional competencies required of RNs practicing in Ohio.
An RN in Ohio should also be willing to carry out an order from an authorized person unless the nurse believes the order is inaccurate, not properly authorized, outdated, invalid, potentially harmful, or contraindicated (Ohio Board of Nursing, 2013). The law essentially defines under what circumstances a nurse can refuse to carry out an order from a doctor or nurse practitioner, thereby reducing the chances that a nurse will be confronted by an irresolvable ethical dilemma. Ohio law also requires a nurse to tell the patient why the medication or treatment should not be given and notify the doctor or nurse practitioner why the order should not be carried out. In essence, Ohio law give fiduciary (ethical) duties to a licensed nurse to protect patients from medical errors by protecting the nurse legally when contraindications occur. Under Ohio law, therefore, the nurse becomes an important safeguard protecting patients from iatrogenic harm.
The rest of the provisions in Chapter 4723-4-03 OCR continue to delineate the responsibilities of licensed nurses in Ohio (Ohio Board of Nursing, 2013). These provisions include the nurse taking an active role in determining the course of treatment for a patient, protecting patient confidentiality, sharing information with colleagues in the interest of patient care, and instruct licensed practical nurses only after the RN has met with and assessed the patient's care need.
Meeting the criteria for nursing professionals under Ohio law is not always straightforward based on my experience. Old habits regarding patient confidentiality, developed in the pre-HIPAA era, are changing slowly. Providers are not always cognizant that information discussed over the phone can be overheard by nearby clinic staff, patients, and family members. Impromptu discussions in elevators when others are around have decreased in frequency, but they have not been eliminated. The rest of the provisions amount to common sense and in my experience creates little or no difficulties in a clinical setting.
The ANA Code of Ethics has nine provisions that define the ethical responsibilities of professional nurses (ANA, 2011). Provision 7 states that one of the ethical obligations of a nurse is to be actively engaged in making personal contributions to nursing practice, education, knowledge, and management. Provision 8 encourages nurses to engage other health care professionals in collaborative efforts to address the health care needs of community, nation, and world. In Provision 9, nurses are encouraged to emphasize adherence to professional nursing values in their duties and to communicate these values to the public through professional organizations.
The ANA Code of Ethics provisions mentioned above describes a nurse's obligations to community and beyond as more than simply providing patient care (ANA, 2011). A nursing 'professional' should also strive to be active in nursing research, implementing evidence-based practice, taking on greater responsibility, making significant contributions to health care policy decisions, and acting as ambassadors for their profession. In practice, however, many nurses are simply trying to provide the best patient care possible while taking care of the needs of their own families. These three provisions do provide guidance for how nursing professionals can contribute to the nursing profession and human health when in a position to do so.
A number of different philosophical theories on values and ethics have contributed to modern nursing ethics (Kurtz and Burr, 2009). Aristotle (384-382 BCE) advocated working to become a virtuous person through practicing actions and goals that bring personal success in moderation. Doing so would help a person become virtuous and of good character. Aristotle also believed that simply performing a good act does not necessarily imply good character, because the context and intent is important as well. The Florence Nightingale Pledge identifies some of the character traits attributed to good character in nurses, but these have become obsolete in modern medicine and society.
Some of the character traits viewed as desirable in nursing professionals in a modern era include compassion, discernment, trustworthiness, and integrity, but probably the most influential ethical theories in modern medicine is utilitarianism and deontological ethics (Kurtz and Burr, 2009). Utilitarian ethics holds that whatever provides the most benefit for the most people would be considered an ethical act. Utilitarianism focuses on the outcome, rather than the intent of the actor, to determine the 'rightness' of an act. One of the main drawbacks to utilitarianism is that predicting which action would be the most ethical is sometimes impossible. Still, a utilitarian decision making process plays an important role in situations when a cost-benefit analysis can help determine whether a health care policy is worth implementing.
Deontological ethical theories essentially encompass what utilitarian ethics ignores, such as the value of individuals and treating all patients with respect (Kurtz and Burr, 2009). The four concepts that have been identified as constituting a theory of modern bioethics are patient autonomy, first…