ADN vs BSN Nursing Ethics, DECs, and Patient Safety

Introduction: Trust, Complacency, and Nursing Responsibility

Healthcare providers occupy a profound position of trust with respect to the patients in their charge. In the case scenario under examination, an ADN nurse and a transport technician were not sufficiently watchful of an elderly patient due to complacency and the fact that they were engaged in a personal conversation. Although a nurse with an associate's degree (ADN) and a bachelor's-level prepared nurse (BSN) would have different levels of expertise and thus differentiated essential competencies, it is important to note that both nurses would have greater expertise than the transport technician and would carry a higher level of responsibility in this scenario.

According to the Differentiated Essential Competencies (DECs) of the Texas Board of Nursing (2010), "Competencies were designed to demonstrate the progression of expectations across the types of nursing programs based upon educational preparation" (p. vii). Although some competencies are admittedly redundant and overlap exists between the two types of nurses, it remains important to recognize that meaningful differences do exist between the levels of practice.

Background of the DECs and Their Application

The DECs were issued by the Texas Board of Nursing as a means of delineating the scope of practice from the Licensed Vocational Nurse (LVN) to the Registered Nurse (RN) at the doctoral level, in order to ensure consistency of academic curricula and programs across the state. The scope of these competencies has been expanded to place increasing emphasis on patient safety. For example, in relation to the cited scenario, an Advanced Practice Nurse (APN) is required to "implement measures to promote quality and a safe environment for patients, self, and others" and to "communicate and collaborate in a timely manner with members of the interdisciplinary health care team to promote and maintain the optimal health status of patients and their families" (DEC, 2004, p. 8).

Bachelor's-level prepared nurses carry similar responsibilities regarding the promotion of safety and collaboration with all members of a healthcare team. Both types of nurses also have responsibilities for delegating tasks appropriately within the healthcare team. However, BSNs who have graduated from a four-year program must also communicate as leaders with "populations and communities" (DEC, 2004, p. 17). Because of their additional education, they hold a leadership role within the wider scope of healthcare practice and function as teachers when acting in supervisory capacities. While ADNs may act in a supervisory role over individuals such as the technician in this scenario, a BSN is charged with acting "using best practices of management, leadership, and evaluation" skills (DECs, 2004, p. 18).

Legal Requirements and Competencies After a Patient Fall

After the patient in the case scenario experienced a fall, both the ADN and BSN were obligated to "comply with mandatory reporting requirements of the Texas Nursing Practice Act" and to report the incident. Going forward, both nurses should also accept further training and instruction to ensure that such an incident does not recur, in keeping with the expectation that nurses should "obtain instruction, supervision, or training, as needed, when implementing nursing procedures or practices" (DECs, 2004, p. 18). Both nurses also had a prior duty to evaluate the patient's initial health status — an obligation that was not adequately fulfilled, given that the patient had been experiencing diarrhea and weakness.

As noted by Brent (2013), particularly when dealing with vulnerable populations such as the elderly, nurses often have a legal as well as an ethical obligation to report any issues they encounter when providing care. This obligation extends beyond their own errors; it also encompasses the errors of other healthcare providers. In other words, a nurse would be required to report the technician's failure to provide adequate care in addition to her own. Mandatory reporting statutes include a requirement to report all injuries that the nurse has a good-faith belief have arisen from neglect — not only injuries caused by the nurse herself, but those caused by other providers as well (Brent, 2013). Legally, a nurse will not be penalized, regardless of the case outcome, if the reporting is deemed to have been made in good faith (Brent, 2013). From an ethical perspective, the duty to report is deontological — that is, rule-bound in nature — even if no harm ultimately results to the patient.

Conclusion

Although both an ADN and a BSN would be in the wrong in the case scenario described, the BSN carries additional modeling and leadership responsibilities. The longer educational preparation demands that the BSN use her capacity to synthesize information and engage in community-level leadership, thereby setting a standard for other providers regarding the correct level of vigilance around a patient. The BSN should continually strive to act as a nurse, a role model, and a teacher.