1. The Register and Roll
The 1999Act established a single register which records all persons that have met the entry to practice requirements for the registered nurse
The roll records all persons who have met the entry practice requirements for the enrolled nurse.

2. The Enrolled nurse
Is a second level nurse who works under the supervision of the registered nurse

3. Professional Nursing practice Topic 01
National Standards
Professional Nursing practice
Topic 01

4. National Standards
The Australian Nursing and Midwifery Council (ANMC) facilitates national standards for statutory nurse regulatory authorities. These define the minimum core competencies and expected standard of behavior/ conduct of all nurses

5. National Standards
ANMC National Competency Standards for the Registered Nurse and Enrolled Nurse
ANMC Codes of Professional Conduct for Nurses in Australia
ANMC Codes of Ethics for Nurses in Australia

6. Board Endorsed Standards
There are a number of standards that have been developed by national professional nursing/ midwifery organizations.
These can be endorsed by the Nurses Board

7. Board Standards
The Board has developed standards which apply to the practice of nursing/midwifery and development of education programs leading to registration and enrolment
Board standards reflect the Nurses Act, Regulations and contemporary regulatory practices

8. Board Standards Standard for Medication Management
Standard for the Use of Restraint
Standard for Therapeutic Relationships and Professional Boundaries
Standards for Approval of Education Courses
Standards for approval as an Education Provider

9. Board Standards
6. Standards for Authorization for an Enrolled Nurse to practice without the supervision of a registered nurse
7. Professional standards statement for Nurse Practitioner Practice

10. Direct supervision
Means that a registered nurse is present and works with the enrolled nurse observing and directing his or her activities.
The proximity of this supervision is such that immediate intervention is possible if problems occur.
The registered nurse is able to observe and monitor the execution of the enrolled nurse’s activities and retains accountability.

11. Indirect Supervision
Means the registered nurse is not present and supervision is provided by other than direct observation, of an enrolled nurse by a registered nurse.
The absence of proximity of the registered nurse requires processes being in place for the direction, guidance, support and monitoring of the enrolled nurse activities. The registered nurse retains accountability

12. Next week Need to have a copies of Code of Ethics Code of Conduct
ANMC Competencies
Activity - refer to them all three documents

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15. Professional Nursing practice
Part I – Professional Nursing bodies
Part II- Scope of Practice
Part II – competency standards for EN and RN

16. Professional nursing bodies
Part I

17. South Australia
There are two professional bodies that guide nursing practice in South Australia:
The Nurses Board of South Australia (NBSA)
The Australian Nursing Federation (ANF SA Branch)

18. NBSA
Is the statutory body responsible for the administration of the Nurses Act and maintenance of registration records
In administering the Nurses Act it fulfils a particular purpose by providing a set of standards that deal with qualifications, duties and responsibilities within the State.

19. NBSA Some of the activities of The Board includes:
Accountability – The Board requires practicing nurses to maintain registration and enrolment annually with an emphasis on the importance of ensuring competence

20. NBSA
Education
The Board determines the educational preparation of nurses through approving courses that lead to registration and enrolment

21. NBSA Conduct and Competence
The Board ensures that people applying for registration and enrolment have the competence, character, mental and physical capacity expected of the profession.

22. Investigation and adjudication
The Board investigates reports about nurses’ conduct, competence or incapacity and hears matters determining the outcomes to protect the public interest

23. The ANF
Is the largest industrial body representing the interests of nurses in Australia.
The South Australian branch of this organisation is a State Registered Union which represents nurses industrially and professionally – just and the ANF does in other states

24. ANF
The ANF has a dual role, which combines professional and industrial responsibilities
The ANF has had a major impact on the development of nursing as a profession

25. ANF
Has provided nurses with guidelines and contribute to the development of the Australian Nursing Council (ANMC) standards for the Registered and Enrolled Nurse
It has also developed standards for self appraisal and the relevant documentation for nursing care to be measured

26. Legal Context
The creation of a set of standards within nursing has had a major impact on the degree of accountability and responsibility of both registered and enrolled nurses and has helped define their roles
With these guidelines in place, the legal system is then provided with parameters within which nursing is performed

27. You as an Enrolled Nurse
As an enrolled nurse, your role and function are defined by the Nurses Board, ANF, your job description and the health unit’s policies and procedures.
How you practice these guidelines is influenced by your level of responsibility and accountability.

28. Nurse’s contract with society
Nursing exists to satisfy a fundamental need of humanity.
Nurses are in a position to be aware of injustices in the health care system and the political arena; therefore, they have a duty to set an example and become involved.

29. Nurses’ professional role
Nurses want the rights and privileges that accompany their professional role, but they do not always want the responsibilities that accompany these rights.
It is not enough for nurses to simply care for patients; they must advocate, educate and set and example to the public

30. Nurses’ professional role
Many nurses do not want theses rights of responsibilities preferring instead to focus on clinical tasks only.
What is wrong with this?????

31. Nurses’ professional role
This mentality is dangerous for nursing
It will prevent nursing from progressing to a higher professional level.
If the main focus of the profession is task-orientated rather than visionary, nursing will lose the battle for patient orientated health care and greater respect for the nursing profession

32. Leadership
Having visionary nursing leaders in strategic positions in health care facilities, professional organisations, and in local and national offices, increases the influence of nurses and therefore, their objective in the health care political arena

33. Ethical obligations
On community and national levels nurses have an ethical obligation to promote human rights awareness and influence health care policies.

34. Benchmarks Rules of guidelines we work under, standards we meet.
Nursing is regulated by many legislative acts and regulations ( as listed on NBSA website)
All nurses must be particularly well aware of the implications of The Nurses Act and the Consent to Medical Treatment and Palliative Care Act 1995.

35. Nurses Board What is it’s function under the Nurses Act 1999 To nurses
To the public

36. Key Terms and what do they mean to your practice
Supervision
Accountability
Responsibility

37. What are national standards
ANMC standards for EN’s
ANMC Code of Professional Conduct
ANMC Code of Ethics for Nurses

38. Board Endorsed Standards
Reflect the Nurses Act, Regulations and contemporary regulatory practices

39. Policies and Procedures
Organizational policy and procedures are essential to guide nursing practice within that particular organisation.
They protect your practice within the workforce.

40. Policy and Procedure Statements: How important are they?
Take these seriously
Often failure to follow protocol that gives the court cause to review nursing practice
Take care reading them – responsibility for failing to do so will lie with the practitioner
Linda Saunders 7/12/04

41. Impact on Enrolled Nursing Practice
Regulates the profession. Currently not all health professionals are regulated.
Only registered or enrolled nurses are entitled to be called ‘nurse’
Nurses must function in accordance with Nurses Act and legislation.
Nurses must have an understanding of the legal implication which effect their practice

42. Impact on Enrolled Nursing Practice
Be aware of standards for restraint
False imprisonment
Tort of negligence
Duty of Care
Vicarious Liability

43. Impact on Enrolled Nursing Practice
Conduct nursing in a way that can be ethically justified according to code of ethics and professional code
Respect the rights of individuals
Accepts accountability and responsibility for own actions within practice
Assess their own practice

44. Impact on Enrolled Nursing Practice
Maintain own professional development
Practice in a safe manner
Maintain professional confidentiality
Ensures informed decision making
Verifies consent for procedures
Aware what constitutes assault/ battery
Understands advocacy
Can identify the moral commitments of the profession.

45. Review of the Nurses Act
The Nurses Act is currently under review
Consultation is underway with all colleges of nursing and general nurses and midwives

46. Key Issues for inclusion of amendment
A separate midwifery register
Regulation of students of nursing
Definition of nurse practitioner
Authority for prescribing of medication for nurse practitioners and midwives
Definitions of delegation, direct and indirect supervision

47. Key Issues for inclusion of amendment
Evidence for continuing competence and scope of practice
Review of the composition of the Board
Review of authorization of enrolled nurses without supervision
Review of investigation and formal proceedings and processes

48. Why change?
The Minister for Health has requested a review of professional registration Acts.
The Medical Practice Bill 2004 and Podiatry Practice Bill have both been tabled in the House of Assembly in
It is likely the new Act will be changed to the Nurses and Midwives Act

49. Taken from a talk by Linda Saunders 7/12/04
Hot topics
Taken from a talk by Linda Saunders 7/12/04

50. We now work in an environment
That has alternative models of care from traditional hospital focus
What are they?
Linda Saunders 7/12/04

51. Alternative care models
Impact of day surgery. Less time to access patients
Primary health care.
Linda Saunders 7/12/04

52. Advances in Technology
The Internet
Research : legal implications
Linda Saunders 7/12/04

53. Fear of litigation Most health professionals fear being sued
Personally and professionally devastating
No more at risk than other members of the community
All have a responsibility to avoid causing personal and property damage
Most litigation in health care settings attributed to unsafe practice, negligent delegations or supervision of staff.
Linda Saunders 7/12/04

54. Medical Litigation Explosion or Media Sensationalism
555 million Medicare services a year
1.1 million hospital admissions
At any one time 450 claims for all kinds of medical negligence in Australian courts collected over 2-3 years
Obstetric litigation expensive and protracted due to the extent of time a claim can be made and the need to investigate time from conception to birth
4% get to court
1% get to hearing
Linda Saunders 7/12/04

55. Case of Sophie Heatcote
Registered nurse on night duty at Wilcannia Hospital
Death in custody of Mark Anthony Quayle
Follow policy
Document clearly
Maintain a professional demenour
Activity – read the case
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56. Go through a day at work
Go through the tasks you will perform in a single working day
Eg take handover
Perform ADL’s
Administer medications
Document
Speak to relatives
Admit and discharge patients
Patient education

57. What legal and ethical parameters impact on your day to day practice?

58. Ethics Topic 03 Ethics Theories Principles
Resolving ethical dilemmas – models of decision making
Discontinuing treatment
Not for resuscitations

59. Principle Based Ethics
Autonomy
Beneficence
Non-malificence
Justice

60. 1. Principle of Autonomy
Humans have the right to non – interference when making decisions about themselves
Free will , without any pressure ???
Health information asymmetry
Forms the basis of ideas about privacy, confidentiality, veracity, fidelity and consent

61. a. Confidentiality
Not reveling information collected from the patient:
Verbally
Examination
Records
Complicated process
Educate staff
Security of Medical documents

62. b. Privacy Areas where patient does not want to reveal :
History
Examinations
Complicated process:
Social harm
Social benefit
Use your common sense

63. c.Veracity Revealing truthful information to the patient:
As a professional
Cultural /social /Medical
harm
Benefit

64. d. Fidelity Practicing within the boundaries of Nursing
Scope of practice
Professional standards

65. e. Consent Intervention Wiliness to agree to undergo any intervention
Implied
Verbal
Written

66. 2. Principle of Beneficence
“I will use treatment for the benefit of the sick, according to my ability and judgment”
Hippocratic Oath
Conduct is aimed at the good and well being of others
Principle requires that practitioners provide both appropriate treatment and an assurance that the treatment will not produce more harm than good

67. 3. Principle of Non-malificence
“Above all do no harm” -Hippocratic Oath
In health care the ethical issues of non-malificence and beneficence are particularly apparent in decisions regarding the institution of dangerous therapy or withdrawal of therapy that is no longer thought to be beneficial.

68. 4. Principle of Justice Justice as fairness Comparative Justice
Distributive Justice

69. Identify the ethical problem
Is it ethically reasonable to allow a person to stop eating and drinking
This situation was complicated by the fact that JD was unable to communicate and may or may not be confused, or in fact mentally competent

70. Mental competence
We cannot proceed further with solving this ethical question until we decide if JD is mentally competent.
If after examination Mr. D is considered mentally competent and able to communicate then continuing to drip feed him is an unbearable assault on his person and the decision to forgo treatment is straight forward

71. If JD is not competent
‘Can we ethically refrain from providing food and fluid to a mentally incompetent individual who appears to have a poor quality of life but will need to be restrained by force to feed him’

72. What facts are available?
Will he be likely to suffer more from not feeding him or restraining him and forcing food upon him?

73. Consider the four principles
In JD’s case we cannot negotiate fully with him as he is not mentally competent. So in order to respect his autonomy, we must fallback on other ways of dealing with him, such as involving family or close friends, ascertaining whether he has left instructions about what do in this circumstance (advance directives)

74. Consider the four principles
Although we wish to do our best to help him, we are still unsure as to whether he will be best served by being allowed to die or by being forced to live.
Which option will entail the greater burdens?
Which option will afford him and his family the most justice?

75. There is no single answer
A solution will only be obtained from collaboration within the health team and with others who are close to the patient
Issues of justice, most commonly resource allocation may become important

76. Identifying ethical conflicts
There is a conflict between the principle of beneficence and non-malificence.
We wish to help this man, but we are unsure if our help will actually harm him

77. Consider the Law
We need to enquire of relatives whether JD had expressed views about treatment he would have declined.
In this case his wishes should be considered when deciding treatment.
None of the proposed courses of conduct would appear to be deliberating intended to end JD’s life (which would be illegal)

78. Consider the Law
A court if asked to consider this issue would probably not consider the withdrawal of treatment (artificial nutrition and hydration) to be the primary cause of JD’s death.
In this instance the approach that a legal enquiry would follow would be the similar to that of ethics.

79. Making the Clinical Decision
Gather all the relevant information and communicate between health professionals, patients, families and between members of the health team.
The decision should be discussed with all concerned and documented clearly in the notes, specifying who was involved in making the decision and why the decision was made.

80. Making the clinical decision
The decision should be reviewed at intervals as determined by the clinical context.
The decision may be reviewed after the patient has died, by a clinical audit, the coroner, and the legal system
It is important that individual practitioners evaluate their own moral decisions

81. Clinical Ethics Since the 1970’s clinical ethics has developed.
Clinical ethics committees have emerged within all institutions
They can assist with promoting and enhancing shared decision making.

82. Ethics and Nursing
Ethics when applied to nursing is the standard of behaviour which nurses are expected to follow in the interest of the public good
A nursing code of ethics provides nurses with guidelines which the standards of practice for the profession are conceived, preserved and refined.

83. Code of Ethics for Nurses in Australia
Has been developed for nursing in the Australian context and is relevant to all nurses in all practice settings
The code of ethics outlines the nursing profession’s intention to accept the rights of individuals and to uphold these rights in practice.

84. Code of Ethics for Nurses in Australia
Its purpose is to:
Identify the fundamental moral commitments of the profession
Provide nurses with a basis for professional and self reflection on ethical conduct

85. Purpose Act as a guide to ethical practice
Indicate to the community the moral values which nurses can be expected to hold.
The code contains six broad value statements with explanatory notes

86. Personal Moral Stance
Nurses may adopt a personal moral stance that would make participation in certain procedures morally unacceptable to them.
Nurses have a right to refuse to participate in procedures which they judge on strongly held moral beliefs to be unacceptable, however they must ensure the quality of care and patient safety are not compromised.

87. A framework for nursing ( 02)
The Code of Ethics is supported by the Code of Professional Conduct for Nurses in Australia. The Code of Ethics focuses on the ethics and ideals of the profession.

88. Code of Ethics

89. Code of Ethics Value statement 1
Nurses respect individual needs, values, culture and vulnerability in the provision of nursing care

90. Code of Ethics Value statement 2
Nurses accept the rights of individuals to make informed choices in relation to their care

91. Code of Ethics Value Statement 3
Nurses promote and uphold the provision of quality nursing care for all people

92. Code of Ethics Value Statement 4
Nurses hold in confidence any information obtained in a professional capacity, use professional judgment where there is a need to share information for the therapeutic benefit and safety of a person and ensure that privacy is safeguarded

93. Code of Ethics Value Statement 5
Nurses fulfill the accountability and responsibility inherent in their roles

94. Accountability and Responsibility
Accountability: the state of being answerable for one’s decisions and actions. It cannot be delegated.
Responsibility: the obligation that an individual assumes when undertaking to carry out planned/ delegated functions. The individual who authorizes the delegated function retains accountability

95. Code of Ethics Value Statement 6
Nurses value environmental ethics and a social, economic and ecologically sustainable environment that promotes health and well being

96. Code of Professional Conduct

97. Code of Professional Conduct
Identifies the minimum requirements for practice in the profession, and focuses on the clarification of professional misconduct and unprofessional conduct.
The two Codes, together with published practice standards, provide a framework for nursing.

98. The Code of Professional Conduct
The purpose of the Code of Professional Conduct for nurses in Australia is to:
Set an expected national standard of conduct for the nursing profession
Inform the community of the standards &
Provide consumer, regulatory, employing and professional bodies with a basis for decisions regarding standards of professional conduct

99. Code of Professional Conduct
A nurse must:
Practice in a safe and competent manner
Practice in accordance with the agreed standards of the profession
Not bring discredit upon the reputation of the nursing profession
Respect the dignity, culture, values and beliefs of an individual and any significant other person

100. Code of Professional Conduct
Support the health, well being and informed decision making of an individual
Promote and preserve the trust that is inherent in the privileged relationship between a nurse and an individual, and respect both the person and property of that individual

101. Code of Professional Conduct
Treat personal information obtained in a professional capacity as confidential
Refrain from engaging in exploitation, misinformation and misrepresentation in regard to health care products and nursing services

102. Competencies
There are professional and ethical competency units within the ANMC Enrolled Nurse Competencies which are endorsed by the Nurses Board.
Enrolled nurses are expected to function in accordance with legislation, policies and procedures affecting nursing practice
They are expected to conduct nursing practice in a way that can be ethically justified

103. Professional Competence
Professionals are expected to internalise the standards of the profession that guide their day- to- day work

104. Is it lawful to disguise medication in the patient’s food?
Ethical issues breach of trust?????
Legal issues duty of care?????
Does it matter if it is medication for a physical or psychological ailment?
Linda Saunders 7/12/04

105. Unclear……..
Should not be a practice adopted to meet time issues associated with inadequate staff levels
Ultimately may meet duty of care
Should be open and transparent
Discuss with next of kin/care team
Formalize as part of the care plan,
Sets a standard of care for that person
Linda Saunders 7/12/04

106. Case scenarios
A law student left arm was amputated after 03 of applying POP plaster .

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