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Chapter 2

Ethical, Legal, andEconomicFoundations of the Educational Process

M. Janice Nelson

KEY TERMS

25

CHAPTER HIGHLIGHTS

A Differentiated View of Ethics, Morality,and the Law

Evolution of Ethical and Legal Principlesin Health Care

Application of Ethical and Legal Principlesto Patient Education

Autonomy Veracity ConfidentialityNonmalfeasanceBeneficence Justice

Legality of Patient Education and InformationDocumentation Economic Factors of Patient Education: Justice

and Duty RevisitedFinancial Terminology

Direct Costs Indirect Costs

Cost Savings, Cost Benefit, and Cost Recovery Program Planning and Implementation Cost-Benefit Analysis and Cost-Effectiveness

AnalysisState of the Evidence

❑ ethical❑ moral❑ legal❑ autonomy❑ veracity❑ confidentiality❑ nonmalfeasance❑ negligence❑ malpractice

❑ beneficence ❑ justice ❑ respondeat superior❑ direct costs❑ fixed costs❑ variable costs❑ indirect costs❑ cost savings❑ cost benefit

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26 Chapter 2: Ethical, Legal, and Economic Foundations

OBJECTIVES

After completing this chapter, the reader will be able to

1. Identify the six major ethical principles. 2. Distinguish between ethical and legal dimensions of the healthcare delivery system, includ-

ing patient and staff education. 3. Describe the importance of nurse practice acts.4. Describe the legal and financial implications of documentation.5. Delineate the ethical, legal, and economic importance of federal, state, and accrediting body

regulations and standards in the delivery of healthcare services.6. Differentiate among financial terms associated with the development, implementation, and

evaluation of patient education programs.

Today as never before in the evolution of thehealthcare field, there is a critical conscious-ness of individual rights stemming from bothnatural and constitutional law. Healthcareorganizations are laden with laws and regu-lations ensuring clients’ rights to a qualitystandard of care, to informed consent, andsubsequently to self-determination. Conse-quently, it is crucial that the providers of carebe equally proficient in both educating thepublic and in educating nursing students andstaff who are or will be the practitioner edu-cators of tomorrow.

Although the physician is primarily heldlegally accountable for the medical regimen, itis a known fact that patient education generallyfalls to the nurse. Indeed, given the close rela-tionship of the nurse to the client, the role of thenurse in this educational process is absolutelyessential and mandated as such through a vari-ety of state nurse practice acts.

We are indeed living in an age of an enlight-ened public that is not only aware, but alsodemands recognition of individual constitu-tional rights regarding freedom of choice andrights to self-determination. In fact, it mayseem curious to some that federal and state gov-ernments, accrediting bodies, and professionalorganizations find it necessary to legislate, reg-ulate, or provide standards and guidelines toensure the protection of human rights when itcomes to matters of health care. The answer, ofcourse, is that the federal government has aban-doned its historical hands off policy towardphysicians and other health professionals in thewake of serious breaches of public confidenceand shocking revelations of abuses of humanrights in the name of biomedical research.

These issues of human rights are fundamen-tal to the delivery of quality healthcare services.They are equally fundamental to the educationprocess, in that the intent of the educator should

❑ cost recovery❑ revenue generation❑ cost-benefit analysis

❑ cost-benefit ratio❑ cost-effectiveness analysis

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A Differentiated View of Ethics, Morality, and the Law 27

be to empower the client to make informedchoices and to be in control of the consequencesof those choices regardless of the outcome. Thus, in explicating the role of the nurse in the teaching–learning process, it would be remiss toomit the ethical and legal foundations of thatprocess.Also, in the interest of justice, whichrefers to the equal distribution of benefits andburdens, it is important to acknowledge therelationship of costs to the healthcare facility inthe provision of such services. Teaching andlearning principles, with their inherent legaland ethical dimensions, apply to any situationin which the educational process is occurring.

The purpose of this chapter is to provide theethical, legal, and economic foundations thatunderpin the patient education initiative on theone hand and the rights and responsibilities ofthe provider on the other. This chapter exploresthe differences between and among ethical, moral,and legal concepts. It explores the ethical andlegal foundations of human rights, and it reviewsthe ethical and legal dimensions of health care.Furthermore, this chapter examines the impor-tance of documentation of patient teaching whilehighlighting the economic factors that must beconsidered in the delivery of patient education inhealthcare settings. An additional section pro-vides a brief discussion of evidence-based practiceand its relationship to quality and evaluation ofpatient education programs.

A Differentiated View of Ethics, Morality, and the LawAlthough ethics as a branch of classical philoso-phy has been studied throughout the centuries,by and large these studies were left to the

domains of philosophical and religious thinkers.More recently, due to the complexities of modern-day living and the heightened awareness of aneducated public, ethical issues related to healthcare have surfaced as a major concern of bothhealthcare providers and recipients of these ser-vices. Thus, it is a widely held belief that theclient has the right to know his or her medicaldiagnosis, the treatments available, and the ex-pected outcomes. This information is necessaryso that informed choices by clients relative totheir respective diagnoses can be made in concertwith advice offered by health professionals.

Ethical principles of human rights are rootedin natural laws, which, in the absence of anyother guidelines, are binding on human society.Inherent in these natural laws are, for example,the principles of respect for others, truth telling,honesty, and respect for life. Ethics as a disci-pline interprets these basic principles of behav-ior in broad terms that guide moral decisionmaking in all realms of human activity (Tong,2007).

Although multiple perspectives on the right-ness or wrongness of human acts exist, among themost commonly referenced are the writings of the16th-century German philosopher, ImmanuelKant, and those of the 19th-century Englishscholar and philosopher, John Stuart Mill(Edward, 1967). Kant proposed that individualrights prevail and openly proclaimed the deonto-logical notion of the “Golden Rule.” Deontology(from the Greek word deon, which means duty)is the ethical belief system that stresses theimportance of doing one’s duty and following therules. Thus, respect for individual rights is keyand one person should never be treated merely asa means to another person’s benefit or a group’swell-being (Tong, 2007). Mill, on the other hand,proposed the teleological notion or utilitarian

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approach to ethical decision making that allowsfor the sacrifice of one or more individuals so thata group of people can benefit in some importantway. He believed that given the alternatives,choices should be made that result in the great-est good for the greatest number of people.

Likewise, the legal system and its laws arebased on ethical and moral principles that,through experience and over time, society hasaccepted as behavioral norms (Hall, 1996;Lesnick & Anderson, 1962). This relationshipaccounts in part for the fact that the terms ethi-cal, moral, and legal are so often used in syn-chrony. It should be made clear, however, thatwhile these terms are certainly interrelated, theyare not necessarily synonymous.

Ethics refers to the guiding principles ofbehavior, and ethical refers to norms or stan-dards of behavior. Although the terms moral ormorality are generally used interchangeablywith the terms ethics or ethical, one can differ-entiate the notion of moral rights and dutiesfrom the notion of ethical rights and duties.Moral refers to an internal value system (themoral fabric of one’s being) and this value sys-tem, defined as morality, is expressed externallythrough ethical behavior. Ethical principlesdeal with intangible moral values, so they arenot enforceable by law, nor are these principleslaws in and of themselves. Legal rights andduties, on the other hand, refer to rules govern-ing behavior or conduct that are enforceableunder threat of punishment or penalty, such asa fine, imprisonment, or both.

The intricate relationship between ethics andthe law explains why ethics terminology, suchas informed consent, confidentiality, non-malfeasance, and justice, can be found withinthe language of the legal system. In keepingwith this practice, nurses may cite professional

commitment or moral obligation to justify theeducation of clients as one dimension of theirrole. In reality, the legitimacy of this role stemsfrom the nurse practice act that exists in the par-ticular state where the nurse resides, is licensed,and is employed. In essence, the nurse practiceact is not only legally binding, but it is also pro-tected by the police authority of the state in theinterest of protecting the public (Brent, 2001;Mikos, 2004).

Evolution of Ethical and Legal Principles in Health Care In the past, ethics was relegated almost exclu-sively to the philosophical and religious domains.Likewise, from a historical vantage point, med-ical and nursing care was considered a humani-tarian, if not charitable, endeavor. Often it wasprovided by members of religious communitiesand others considered to be generous of spirit,caring in nature, courageous, dedicated, and self-sacrificing in their service to others. Public sen-timent was so strong in this regard that for manyyears healthcare organizations, which were con-sidered to be charitable institutions, were largelyimmune from legal action “because it wouldcompel the charity to divert its funds for a pur-pose never intended” (Lesnik & Anderson, 1962,p. 211). In the same manner, healthcare practi-tioners in the past—who were primarily physi-cians and nurses—were usually regarded as GoodSamaritans who acted in good faith.

Although there are numerous court records oflawsuits involving hospitals, physicians, andnurses dating back to the early 1900s, thosenumbers pale in comparison with the volumesbeing generated on a daily basis in today’s world

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Evolution of Ethical and Legal Principles in Health Care 29

(Reising & Allen, 2007). Further, despite the hor-ror stories that have been handed down throughthe years regarding inhumane and often tortur-ous treatment of prisoners, the mentally infirm,the disabled, and the poor, there was limited fo-cus in the past on ethical aspects of that care. Inturn, there was little thought of legal protectionfor the rights of such mentally, physically, orsocioeconomically challenged people.

Clearly, this situation has changed dramati-cally. Informed consent, for example, which isa basic tenet of ethical thought, was establishedin the courts as early as 1914 by JusticeBenjamin Cardozo. Cardozo determined thatevery adult of sound mind has a right to protecthis or her own body and to determine how itshall be treated (Hall, 1992; Schloendorff v. Societyof New York Hospitals, 1914). Although theCardozo decision was of considerable magni-tude, governmental interest in the bioethicalunderpinnings of human rights in the deliveryof healthcare services did not really surface untilafter World War II.

Over the years, legal authorities such as fed-eral and state governments maintained a hands-off posture when it came to issues of biomedicalresearch or physician–patient relationships.However, human atrocities committed by theNazis in the name of biomedical research duringWorld War II shocked the world into criticalawareness of gross violations of human rights.Unfortunately, such abuses were not confined towartime Europe alone. On United States soil, forexample, the nontreatment of syphilitic AfricanAmericans in Tuskegee, Alabama; the injectionof live cancer cells into uninformed, noncon-senting older adults at the Brooklyn ChronicDisease Hospital; and the use of institutionalizedmentally retarded children to test hepatitis vac-cines at Willowbrook Developmental Center on

Staten Island, New York, shocked the nation andraised a critical consciousness of disturbingbreaches in the physician–patient relationship(Brent, 2001; Centers for Disease Control andPrevention, 2005; Rivera, 1972; Thomas &Quinn, 1991; Weisbard & Arras, 1984).

Stirred to action by these disturbing phe-nomena, in 1974 Congress moved with all duedeliberation to create the National Commission forthe Protection of Human Subjects of Biomedical andBehavioral Research (Department of Health andHuman Services [DHHS], 1983). As an outcomeof this unprecedented act, an institutional reviewboard for the protection of human subjects(IRBPHS) was rapidly established at the locallevel by hospitals, academic medical centers, andany agency or organization where research onhuman subjects was being conducted. To thisday, the primary emphasis of these review boardsis on confidentiality, truth telling, and informedconsent, with specific concern for vulnerable pop-ulations such as infants, children, prisoners, andthe mentally ill. Every proposal for biomedicalresearch that involves human subjects must besubmitted to a local IRBPHS for intensive reviewand approval before proceeding with a proposedstudy (DHHS, 1983). Further, in response to itsconcern about the range of ethical issues associ-ated with medical practice and a perceived needto regulate biomedical research, in 1978 Congressestablished the President’s Commission for theStudy of Ethical Problems in Medicine andBiomedical and Behavioral Research (Brent,2001; DHHS, 1983; Thomas & Quinn, 1991).

Interestingly, as early as 1950, the AmericanNurses Association (ANA) developed andadopted an ethical code for professional practicethat has since been revised and updated severaltimes (ANA, 1976, 1985, 2001). The latest revi-sion of the ANA’s code, now entitled the Code of

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Ethics for Nurses With Interpretive Statements, wasreleased in 2001 for implementation in the newmillennium. This code represents an articulationof professional values and moral obligations inrelation to the nurse–patient relationship and insupport of the profession and its mission.

In 1975, the American Hospital Association(AHA) followed suit by disseminating a docu-ment entitled Patient’s Bill of Rights, which wasrevised in 1992 (Association of American Phy-sicians and Surgeons, 1995). A copy of thesepatient rights is framed and posted in a publicplace in every healthcare facility across theUnited States. In addition, federal standardsdeveloped by the Center for Medicare andMedicaid Services (CMS)—an arm of the HealthCare Financing Administration (HCFA)—require that the patient be provided with a per-sonal copy of these rights either at the time ofadmission to the hospital or long-term carefacility or prior to the initiation of care or treat-ment when admitted to a surgicenter, an HMO,home care, or a hospice. As a matter of fact,many states have adopted the statement ofpatient rights as part of their state health code.Thus these rights fall under the jurisdiction ofthe law, rendering them legally enforceable bythreat of penalty.

Application of Ethical and Legal Principles toPatient Education In considering the ethical and legal responsibil-ities inherent in the process of patient educa-tion, six major ethical principles are intricatelywoven throughout the ANA’s Code of Ethics(2001), the AHA’s Patient’s Bill of Rights (1992),and similar documents promulgated by otherhealthcare organizations as well as the federal

government. These principles, which encompassthe very issues that precipitated federal inter-vention into healthcare affairs, are autonomy,veracity, confidentiality, nonmalfeasance, benef-icence, and justice.

AutonomyThe first of these principles, autonomy, is derivedfrom the Greek words auto (self) and nomos (law)and refers to the right of self-determination(Tong, 2007). Laws have been enacted to protectthe patient’s right to make choices indepen-dently. Federal mandates, such as informed con-sent, must be evident in every application forfederal funding to support biomedical research.The local IRBPHS assumes the role of judge andjury to ascertain adherence to this enforceableregulation (Dickey, 2006).

The Patient Self-Determination Act (PSDA),which was passed by Congress in 1991 (Ulrich,1999), is a clear example of the principle ofautonomy enacted into law. Any healthcare facil-ity, such as acute- and long-term care institu-tions, surgicenters, HMOs, hospices, or homecare, that receives Medicare and/or Medicaidfunds, must comply with the PSDA. The lawrequires, either at the time of hospital admissionor prior to the initiation of care or treatment ina community health setting, “that every indi-vidual receiving health care be informed in writ-ing of the right under state law to makedecisions about his or her health care, includingthe right to refuse medical and surgical care andthe right to initiate advance directives” (Mezey,Evans, Golob, Murphy, & White, 1994, p. 30).These authors readily acknowledge the nurse’sresponsibility to ensure informed decision mak-ing by patients, which includes but is certainlynot limited to advance directives (e.g., livingwills, durable power of attorney, and designa-tion of a healthcare proxy). Documentation of

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Application of Ethical and Legal Principles to Patient Education 31

such instruction must appear in the patient’srecord, which is the legal document validatingthat informed consent took place.

One principle worth noting in the ANA’s Codeof Ethics is that which addresses collaboration“with members of the health professions andother citizens in promoting community andnational efforts to meet the health needs of thepublic” (New York State Nurses Association,2001, p. 6). Although not specified in such detailin the ANA document, this principle certainlyprovides a justification for patient education bothwithin and outside the healthcare organization.It provides an ethical rationale for health educa-tion classes open to the community, such as child-birth education courses, smoking cessationclasses, weight reduction sessions, discussions ofwomen’s health issues, and positive interventionsfor preventing child abuse. While health educa-tion, per se, is not an interpretive part of the prin-ciple of autonomy, it certainly lends credence tothe ethical notion of assisting the public to attaingreater autonomy when it comes to matters ofhealth promotion and high-level wellness. In fact,consistent with the Model Nurse Practice Act(ANA, 1978), all contemporary nurse practiceacts contain some type of statements identifyinghealth education as a legal duty and responsibil-ity of the registered nurse.

VeracityVeracity, or truth telling, is closely linked toinformed decision making and informed con-sent. The early 20th-century landmark decisionby Justice Benjamin Cardozo (Schloendorff v.Society of New York Hospitals, 1914) specified anindividual’s fundamental right to make decisionsabout his or her own body. This ruling provideda basis in law for patient education or instructionregarding invasive medical procedures. Nursesare often confronted with issues of truth telling,

as was exemplified in the Tuma case (Rankin &Stallings, 1990). In the interest of full disclosureof information, the nurse (Tuma) had advised acancer patient of alternative treatments withoutconsultation with the client’s physician. Tumawas sued by the physician for interfering withthe medical regimen that he had prescribed forcare of this particular patient. Although Tumawas eventually exonerated from professional mis-conduct charges, the case emphasized a signifi-cant point of law to be found in the New YorkState Nurse Practice Act (1972), which states,“A nursing regimen shall be consistent with andshall not vary from any existing medical regi-men.” In some instances, this creates a doublebind for the nurse. Creighton (1986) emphati-cally explained that failure or omission to prop-erly instruct the patient relative to invasiveprocedures is tantamount to battery.

Cisar and Bell (1995) addressed this conceptof battery related to medical treatment exceed-ingly well. In addition to explaining Curtin’s(1978) Ethical Decision-Making Model, whichserves as a guide for healthcare providers facingan ethical dilemma, the authors offered the fol-lowing explanation of the four elements makingup the notion of informed consent that are suchvital aspects of patient education:

1. Competence, which refers to the capacity ofthe patient to make a reasonable decision.

2. Disclosure of information, which requiresthat sufficient information regardingrisks and alternative treatments be pro-vided to the patient to enable him orher to make a rational decision.

3. Comprehension, which speaks to the indi-vidual’s ability to understand or tograsp intellectually the informationbeing provided. A child, for example,may not yet be of an age to understand

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any ramifications of medical treatmentand must, therefore, depend on his orher parents to make a decision that willbe in the child’s best interest.

4. Voluntariness, which indicates that thepatient has made a decision withoutcoercion or force from others.

While all four of these elements might besatisfied, the client might still choose to rejectthe regimen of care suggested by healthcareproviders. This decision could be due to theexorbitant cost of a treatment or to certain per-sonal or religious beliefs. Whatever the case, itmust be recognized by all concerned that a com-petent, informed client cannot be forced toaccept treatment as long as he or she is aware ofthe alternatives as well as the consequences ofany decision (Cisar & Bell, 1995).

A final dimension of the legality of truthtelling relates to the role of the nurse as expertwitness. Professional nurses who are recognizedfor their skill or expertise in a particular area ofnursing practice may be called on to testify incourt on behalf of either the plaintiff (the onewho initiates the litigation) or the defendant(the one being sued). In any case, the concept ofexpert testimony speaks for itself. Regardless ofthe situation, the nurse must always tell thetruth and the client (or his or her health proxy)is always entitled to the truth (Hall, 1996).

ConfidentialityConfidentiality refers to personal informationthat is entrusted and protected as privilegedinformation via a social contract, healthcarestandard or code, or legal covenant. Such infor-mation may not be disclosed by healthcareproviders when acquired in a professional capac-ity from a patient without consent of that

patient. If sensitive information were not to beprotected, patients would lose trust in theirproviders and would be reluctant to openlyshare problems with them.

A distinction must be made between theterms anonymous and confidential. Informationis anonymous, for example, when researchers areunable to link any subject’s identity in theirrecords. Information is confidential when iden-tifying materials appear on subjects’ records, butcan only be accessed by the researchers (Tong,2007).

Only under special circumstances may secrecybe ethically broken, such as when a patient hasbeen the victim or subject of a crime to which thenurse or doctor is a witness (Lesnick & Anderson,1962). Other exceptions to confidentiality occurwhen professionals suspect or are aware of childor elder abuse, narcotic use, communicable dis-eases, gunshot or knife wounds, or the threat ofviolence toward someone. To protect the welfareof others, professionals are permitted to breachconfidentiality. Another example occurs when apatient tests positive for HIV/AIDS and has nointention of telling his or her spouse about thisdiagnosis. In this instance, the physician is obli-gated to warn the spouse directly or indirectly of the risk of potential harm (Tong, 2007).According to Brent (2001), “this area of legisla-tion concerned with health care privacy and dis-closure reveals the tension between what is goodfor the individual vis-à-vis what is good for soci-ety” (p. 141).

The 2003 updated Health InformationPortability and Accountability Act (HIPAA)ensures nearly absolute confidentiality related todissemination of patient information, unless thepatient himself or herself authorizes release ofsuch information (Kohlenberg, 2006). One goalof the HIPAA policy, first enacted by Congress

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in 1996, is to limit disclosure of patient health-care information to third parties, such as insur-ance companies or employers. This law, whichrequires patients’ prior written consent forrelease of their health information, was nevermeant to interfere with consultation betweenprofessionals, but is intended to prevent eleva-tor conversations about private matters of indi-viduals entrusted to our care. In an open, liberal,and technologically advanced society such asours, this law is a must to ensure confidentiality(Tong, 2007). Today, in some states and undercertain conditions, such as death or impendingdeath, a spouse or members of the immediatefamily can be apprised of the patient’s conditionif this information was previously unknown tothem. Despite federal and state legislation pro-tecting the confidentiality rights of individuals,the issue of the ethical/moral obligation of theperson with HIV/AIDS or genetic disease, forexample, to voluntarily divulge his or her condi-tion to others who may be at risk remainslargely unresolved (Legal Action Center, 2001).

Nonmalfeasance Nonmalfeasance means “do no harm” and consti-tutes the ethical fabric of legal determinationsencompassing negligence and/or malpractice.According to Brent (2001), negligence is definedas “conduct which falls below the standardestablished by law for the protection of othersagainst unreasonable risk of harm” (p. 54). Shefurther asserts that the concept of professionalnegligence “involves the conduct of professionals(e.g., nurses, physicians, dentists, and lawyers)that fall [sic] below a professional standard ofdue care” (p. 55). As clarified by Tong (2007),due care is “the kind of care healthcare profes-sionals give patients when they treat themattentively and vigilantly so as to avoid mis-

takes” (p. 25). For negligence to exist, theremust be a duty between the injured party andthe person whose actions (or nonactions) causedthe injury. A breach of that duty must haveoccurred, it must have been the immediatecause of the injury, and the injured party musthave experienced damages from the injury(Brent, 2001).

The term malpractice, by comparison, stillholds as defined by Lesnick and Anderson in1962. Malpractice, these authors asserted, “refersto a limited class of negligent activities com-mitted within the scope of performance by thosepursuing a particular profession involvinghighly skilled and technical services” (p. 234).More recently, malpractice has been specificallydefined as “negligence, misconduct, or breach ofduty by a professional person that results ininjury or damage to a patient” (Reising & Allen,2007). Thus, malpractice, per se, is limited inscope to those whose life work requires specialeducation and training as dictated by specificeducational standards. In contrast, negligenceembraces all improper and wrongful conduct byanyone arising out of any activity. Reising andAllen (2007) describe the most common causesfor malpractice claims against nurses:

1. Failure to follow standards of care2. Failure to use equipment in a responsi-

ble manner3. Failure to communicate4. Failure to document5. Failure to assess and monitor6. Failure to act as patient advocate7. Failure to delegate tasks properly

The concept of duty is closely tied to the con-cepts of negligence and malpractice. Nurses’duties are spelled out in job descriptions at theirplaces of employment. Policy and procedure

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manuals of a particular facility exist certainly toprotect the patient, but they also exist to pro-tect the employee, in this instance, the nurse,and the employer against litigation. Policies aremore than guidelines. Policies and proceduresdetermine standards of behavior (duties)expected of employees of a particular institutionand can be used in a court of law in the deter-mination of negligence.

Expectations of professional nursing per-formance are also measured against the nurse’slevel of education and concomitant skills, stand-ing orders of the physician, institution-specificprotocols, standards of care upheld by the pro-fession (ANA), and standards of care adhered toby the various clinical specialty organizations ofwhich the nurse may be a member. If the nurseis certified in a clinical specialty or is identifiedas a “specialist” although not certified, he or shewill be held to the standards of that specialty(Yoder Wise, 1995).

In the instance of litigation, the key opera-tional principle is that the nurse is not measuredagainst the optimal or maximum of professionalstandards of performance; rather, the yardstickis laid against the prevailing practice of what aprudent and reasonable nurse would do underthe same circumstances in a given community.Thus, the nurse’s duty of patient education (orlack thereof) is measured against not only pre-vailing policy of the employing institution, butalso against prevailing practice in the commu-nity. In the case of clinical nurse specialists(CNSs), nurse practitioners (NPs), or clinicaleducation specialists (CESs), for example, thepractice is measured against institutional poli-cies for this level of worker as well as against theprevailing practice of nurses performing at thesame level in the community or in the same geo-graphic region.

BeneficenceBeneficence is defined as “doing good” for the ben-efit of others. It is a concept that is legalizedthrough adherence to critical tasks and duties con-tained in job descriptions; in policies, procedures,and protocols set forth by the healthcare facility;and in standards and codes of ethical behaviorsestablished by professional nursing organizations.Adherence to these various professional perfor-mance criteria and principles, including adequateand current patient education, speaks to the nurse’scommitment to acting in the best interest of thepatient. Such behavior emphasizes patient welfare,but not necessarily to the detriment of the well-being of the healthcare provider. That is, the effortto save lives and relieve human suffering is a dutyto do good only within reasonable limits. For ex-ample, when AIDS first appeared, the cause andcontrol of this fatal disease was unknown. Somehealthcare professionals protested that the duty ofbeneficence did not include caring for patientswho put them at risk for this deadly, infectious,and untreatable disease. Once it became clear thattransmission through occupational exposure wasquite small, the majority of healthcare practition-ers concurred with the opinion of the AmericanMedical Association that they “… may not ethi-cally refuse to treat a patient whose condition iswithin [their] current realm of competence solelybecause the patient is seropositive” (Tong, 2007).

Justice The sixth and final ethical principle, justice,speaks to the fairness and equal distribution ofgoods and services. The law is the justice sys-tem. The focus of the law is the protection ofsociety; the focus of health law is the protectionof the consumer. It is unjust to treat a personbetter or worse than another person in a similar

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condition or circumstance, unless a difference intreatment can be justified with good reason. Intoday’s healthcare climate, professionals must beas objective as possible in allocating scarce med-ical resources in a just manner. Decision makingfor the fair distribution of resources includes thefollowing criteria as defined by Tong (2007):

1. To each, an equal share2. To each, according to need3. To each, according to effort4. To each, according to contribution5. To each, according to merit6. To each, according to the ability to pay

(p. 30)

According to Tong, healthcare professionalsmay have second thoughts about the applicationof these criteria in particular circumstancesbecause one or more of the criteria could be atodds with the concept of justice. “To allocatescarce resources to patients on the basis of theirsocial worth, moral goodness, or economic con-dition rather than on the basis of their medicalcondition is more often than not wrong” (p. 30).

As noted earlier, adherence to the Patient’sBill of Rights is legally enforced in most states.This means that the nurse or any other healthprofessional can be subjected to penalty or to lit-igation for discrimination in provision of care.Regardless of his or her age, gender, physicaldisability, sexual orientation, or race, for exam-ple, the client has a right to proper instructionregarding risks and benefits of invasive medicalprocedures. S/he also has a right to properinstruction regarding self-care activities, such ashome dialysis, for example, that are beyond nor-mal activities of daily living for most people.

Furthermore, when a nurse is employed by aparticular healthcare facility, she or he entersinto a contract, written or tacit, to provide nurs-

ing services in accordance with the policies ofthe facility. Failure to provide nursing care(including educational services) based on patientdiagnosis or persistence in providing substan-dard care based on client age, diagnosis, culture,national origin, sexual preference, and the like,can result in liability for breach of contract withthe employing institution.

Most recently, the U.S. Congress has wres-tled with another version of patients’ rightswithin which every American carrying healthinsurance is guaranteed access to emergencyroom care, to treatment by medical specialists,and to government-run clinical trials (Abood,2001; President’s Advisory Commission on Con-sumer Protection and Quality in the HealthcareIndustry, 1998). Also, considerable argumenthas ensued among members of Congress overthe extent to which health maintenance orga-nizations (HMOs) can be sued for delay or de-nial of care, and what limits, if any, should beplaced on the damages (Zuckerman, 2001). Thisfederal legislation adds an interesting dimensionto the notion of justice as it applies to healthcare. The proposed patients’ rights legislation isintended only for those covered by health insur-ance. This restriction raises serious questions forthe uninsured regarding the right of access tohealth care and subsequently the right of accessto health education. Emanuel (2000) raises acritical point in asserting that “the diffusenessof decision making in the American health caresystem precludes a coherent process for allocat-ing health care resources” (p. 8). Emanuel fur-ther contends that managed care organizationshave systematically pursued drastic cost reduc-tions by restructuring of delivery systems andinvesting in expensive and elaborate informa-tion systems. HMOs have bought out physicianpractices and have become involved in a number

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of related activities with no substantial evidencethat a high quality of health care will beachieved at lower prices.

To date, this particular enactment of apatient’s bill of rights and the issues of just orunjust cost-cutting activities of HMOs asdescribed by Emanuel (2000) do, indeed, affectthe role of the educator. These issues determinewhether nurse educators can surmount theobstacles potentially blocking the patient edu-cation process. In the interest of cutting costs,HMOs have also succeeded in shorteninglengths of hospital stays. This development, inturn, has had a tremendous effect on the deliv-ery of education to the hospitalized patient andpresents serious obstacles to the implementationof this mandate. Lack of time serves as a majorbarrier to the nurse in being able to provide suf-ficient information for self-care, and illness acu-ity level interferes with the patient’s ability toprocess information necessary to meet his or herphysical and emotional needs.

Clearly, professional nurses are mandated byorganizational policy as well as by federal andstate regulations to provide patient education.Thus, great care must be taken to ensure that theeducation justly due to the client will beaddressed postdischarge, either in the ambulatorycare setting, at home, or in the physician’s office.

Legality of PatientEducation and Information The patient’s right to adequate informationregarding his or her physical condition, medica-tions, risks, and access to information regardingalternative treatments is specifically spelled out invarious renditions of the Patient’s Bill of Rights

(AHA, 1992; President’s Advisory Commission,1998; ANA, 2001; Association of AmericanPhysicians and Surgeons, 1995). As noted earlier,many states have adopted these rights as part oftheir health code, thus rendering them legal andenforceable by law. Patients’ rights to educationand instruction are also regulated through stan-dards promulgated by accrediting bodies such asthe Joint Commission, formerly known as theJoint Commission on Accreditation of HealthcareOrganizations (JCAHO). Although these stan-dards are not enforceable in the same manner aslaw, lack of organizational conformity can lead toloss of accreditation, which in turn jeopardizes thefacility’s eligibility for third-party reimbursement,as well as loss of Medicare and Medicaid reim-bursement. Lack of organizational conformity canalso lead to loss of public confidence.

In addition, state regulations pertaining topatient education are published and enforcedunder threat of penalty (fine, citation, or both)by the department of health in many states.Federal regulations, enforceable as laws, alsomandate patient education in those healthcarefacilities receiving Medicare and Medicaid fund-ing. And, as discussed earlier, the federal gov-ernment also mandates full patient disclosure incases of participation in biomedical research inany setting or for any federally funded project orexperimental research involving human subjects.

Federal authorities have generally tended tohold physicians responsible and accountable forproper patient education. This is particularlytrue as it pertains to issues of informed consent,such as those highlighted in Scalia v. St. PaulFire and Marine Ins. Co., 1975 (Smith, 1987). Itis a well-known fact—at least in hospitals—thatpatient education usually is carried out by thenurse or some other physician-appointed de-

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Documentation 37

signee. Physicians’ responsibility notwithstand-ing, from a professional and legal vantage point,nurses are fully legitimized in their role aspatient educators by virtue of their respectivenurse practice acts. The issue regarding patienteducation is not necessarily one of omission onanyone’s part. Rather, the heart of the mattermay be proper documentation (or the lackthereof) that provides evidence of written testi-mony that client education has indeed occurred.

Documentation The 89th Congress enacted the ComprehensiveHealth Planning Act in 1965, Public Law 89-97, 1965 (Boyd, Gleit, Graham, & Whitman,1998). The entitlements of Medicare andMedicaid—which revolutionized the provisionof health care for the elderly and the poor—wereestablished through this act. One acknowledg-ment in the act was the importance of the pre-ventive and rehabilitative dimensions of healthcare. Thus, to qualify for Medicare and Medicaidreimbursement, “a hospital has to show evi-dence that patient education has been a part ofpatient care” (Boyd et al., 1998, p. 26).

For at least the past 20 years, the JointCommission (formerly JCAHO) has reinforcedthe federal mandate by requiring evidence (doc-umentation) of patient and/or family educationin the patient record. Pertinent to this point isthe doctrine of respondeat superior, or the master-servant rule. Respondeat superior provides that theemployer may be held liable for negligence,assault and battery, false imprisonment, slander,libel, or any other tort committed by anemployee (Lesnik & Anderson, 1962). The land-mark case supporting the doctrine of respondeatsuperior in the healthcare field was the 1965 case

of Darling v. Charleston Memorial Hospital.Although the Darling case dealt with negli-gence in the performance of professional dutiesof the physician, it brought out—possibly forthe first time—the professional obligations orduties of nurses to ensure the well-being of thepatient (Brown, 1976).

Casey (1995) points out that of all omissionsin documentation, patient teaching has beenidentified as “probably the most undocumentedskilled service because nurses do not recognize thescope and depth of the teaching they do” (p. 257).Lack of documentation also reflects negligence inadhering to the mandates of the particular nursepractice act. This laxity is unfortunate, becausepatient records can be subpoenaed for court evi-dence. Appropriate documentation can be thedetermining factor in the outcome of litigation.Pure and simple, if the instruction isn’t docu-mented, it didn’t occur!

Furthermore, documentation is a vehicle ofcommunication that provides critical informa-tion to other healthcare professionals involvedwith the patient’s care. Failure to document notonly renders other staff potentially liable, butalso renders the facility liable and in jeopardy oflosing its Joint Commission accreditation.Concomitantly, the institution is also in dangerof losing its appropriations for Medicare andMedicaid reimbursement.

In any litigation where the doctrine of respon-deat superior is applied, outcomes can hold theorganization liable for damages (monetary re-tribution). Thus it behooves the nurse as bothemployee and professional not only to providepatient education, but also to document itappropriately and to be critically conscious of thelegal and financial ramifications to the health-care facility in which he or she is employed.

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Snyder (1996) presents an invaluable descrip-tion of an interdisciplinary method to documentpatient education. The method involves use of aflow sheet that fits into the client’s chart. Theflow sheet includes identification of client andfamily educational needs based on a number ofvariables; these include the following:

• Readiness to learn (based on admissionassessment of the client)

• Obstacles to learning, which mightinclude language, lack of vision, orother challenges

• Referrals, which might include a patient advocate, the library, or anethics committee

The form provides documentation space for whowas taught (e.g., client or family), what wastaught (e.g., self-injection of insulin), when itwas taught, what strategies of teaching wereused (instructional methods and materials), andhow the client responded to instruction (whatoutcomes were achieved).

Table 2–1 is a visual representation of the rela-tionship of ethical principles to the laws and pro-fessional standards applicable to each principle. Itshould be noted that the AHA’s 1975 originaldraft rendition of a Patient’s Bill of Rights, alongwith all the later renditions of these rights, arelinked to or associated with every ethical princi-ple. The Patient’s Bill of Rights (AHA, 1992) isrooted in the conditions of participation in Med-icare set forth under federal standards establishedby the Center for Medicare and Medicaid Services(CMS). These standards are further emphasizedby corresponding accreditation standards pro-mulgated by the Joint Commission. All theselaws and professional standards serve to ensurethe fundamental rights of every person as a con-sumer of healthcare services.

Economic Factors of Patient Education: Justice and Duty Revisited

Some might consider the parameters of health-care economics and finances as objective infor-mation that can be used for any number ofpurposes. Fiscal solvency and forecasting of eco-nomic growth of an organization are good exam-ples of this phenomenon. Others would agreethat in addition to the legal considerations thatmandate adherence to regulations in health careregardless of the economics involved, there isalso an ethical dimension that speaks certainlyto quality of care and also to justice, which refersto the equal distribution of goods and services.

In the interest of patient care, the client as ahuman being has a right to quality care regard-less of his or her economic status, national ori-gin, race, and the like. Furthermore, healthprofessionals have a duty to see to it that suchservices are provided. In like manner, thehealthcare organization has the right to expectthat it will receive its fair share of reimbursablerevenues for services rendered.

Thus, as an employee of the provider orga-nization, the nurse has a duty to carry out orga-nizational policies and mandates by acting in anaccountable and responsible manner. This dutyincludes assuming fiscal accountability forpatient education activities, whether these areoffered on an inpatient or ambulatory care basisor as a service to the larger community.

The principle of justice is a critical consid-eration within the discourse on patient educa-tion. The rapid changes and trends so evidentin the contemporary healthcare arena are, forthe most part, economically driven. Describedas chaotic by some, the healthcare system in

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Economic Factors of Patient Education: Justice and Duty Revisited 39

many ways defies the humanistic and charita-ble underpinnings that have characterizedhealthcare services in this country across thedecades. Indeed, organizations that provide

health care are caught between the proverbialhorns of the dilemma of allocating scarceresources in a just yet economically feasiblemanner.

Table 2–1 Linkages Between Ethical Principles and the Law

Legal Actions/Decisions Ethical Principles and Standards of Practice

Autonomy (self-determination)

Veracity (truth telling)

Confidentiality (privileged information)

Nonmalfeasance (do no harm)

Beneficence (doing good)

Justice (equal distribution of benefits and burdens)

Cardozo decision regarding informed consentInstitutional review boardsPatient Self-Determination ActPatient’s Bill of RightsJoint Commission/CMS standards

Cardozo decision regarding informed consentPatient’s Bill of RightsTuma decisionJoint Commission/CMS standards

Privileged informationPatient’s Bill of RightsJoint Commission/CMS standardsHIPAA

Malpractice/negligence rights and dutiesNurse practice actsPatient’s Bill of RightsDarling v. Charleston Memorial HospitalState health codesJoint Commission/CMS standards

Patient’s Bill of RightsState health codesJob descriptionsStandards of practicePolicy and procedure manualsJoint Commission/CMS standards

Patient’s Bill of RightsAntidiscrimination/affirmative action lawsAmericans with Disabilities ActJoint Commission/CMS standards

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On the one hand, the realities of capitationand managed care result in shrinking revenues.This trend, in turn, dictates shorter patient staysin hospitals and doing more with less. Despitecontinued, severe shortages of healthcare per-sonnel in most geographic areas of the country,healthcare facilities are concomitantly expand-ing their clinical expertise into satellite types ofambulatory and home care services. On theother hand, these same organizations are held tothe exact standards of care that are underwrittenby the Patient’s Bill of Rights (AHA, 1992),which is regulated as a contingency of Medicareand Medicaid participation by the CMS and foragency accreditation by the Joint Commission.In turn, although there are some exceptions(e.g., home healthcare agencies), hospitalaccreditation in particular dictates eligibility forthird-party reimbursement in both the publicand private sectors.

Over and above the financial facts, these samecharitable, not-for-profit organizations no longerenjoy the legal immunity that existed in yester-year. The doctrine of respondeat superior is aliveand well. In a Supreme Court decision stemmingfrom Abernathy v. Sisters of St. Mary’s in 1969, thecourt held that a “non-governmental charitableinstitution is liable for its own negligence andthe negligence of its agents and employees act-ing within the scope of their employment”(Strader, 1985, p. 364). The court further de-clared that this ruling would apply to all futurecases as of November 10, 1969. Thus the regu-lated right of clients to health education carriesa corresponding duty of healthcare organizationsto provide that service.

In an environment of shrinking healthcaredollars, continuous shortages of staff, and dra-matically shortened lengths of stay yieldingrapid patient turnover, the organization is chal-lenged to ensure the competency of nursing staff

to provide educational services, and to do so inthe most efficient and cost-effective manner pos-sible. This is an interesting dilemma when con-sidering the fact that patient education isinvariably identified, directly or indirectly, as alegal responsibility of registered nurses in therespective nurse practice acts of all states.Unfortunately, few, if any, prelicensure educa-tion programs adequately prepare nursing stu-dents for this critical function.

Financial TerminologyGiven the fact that the role of the nurse as edu-cator is an essential aspect of care delivery,included is an overview of fiscal terminologythat directly affects both staff and patient edu-cation. Such educational services are not pro-vided without an accompanying cost of humanand material resources. Thus, it is important toknow that expenditures are essentially classifiedinto two categories: direct and indirect costs.

Direct CostsDirect costs are tangible, predictable expendi-tures, a substantial portion of which includepersonnel salaries, employment benefits, andequipment (Gift, 1994). This portion of anorganizational budget is almost always thelargest of the total budgetary outlay of anyhealthcare facility.

Because of the labor-intensive function ofnursing care delivery, the costs of nurses’ salariesand benefits usually account for at least 50%—if not more—of the total facility budget. Ofcourse, the higher the educational level of nurs-ing staff, the higher the salaries and benefits, andthus, the higher the institution’s total direct costs.

Although the purpose of salary is to buy anemployee’s time and particular expertise, it isoften difficult to predict how long it will take to

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Financial Terminology 41

plan, implement, and evaluate various educationalprograms being offered. For example, if planningand carrying out patient or staff education exceedsthe allocated time and the nurse educator drawsovertime pay, the extra cost may not have beenanticipated in the budget planning process.

Time is also considered a direct cost and is amajor factor included in a cost-benefit analysis.In other words, if the time it takes to prepare andoffer patient or staff education programs is greaterthan the financial gain to the institution, thefacility may seek other ways of providing this ser-vice, such as computerized programmed instruc-tion or a patient television channel.

Also, equipment is classified as a direct cost.No organization can function without properequipment and the need to replace it when nec-essary. Teaching requires audiovisual equipmentand tools for instruction, such as overhead pro-jectors, slide projectors, models, copy machines,computers, and closed-circuit televisions.Although renting or leasing equipment maysometimes be less expensive than purchasing it,rental and leasing costs are still categorized asdirect costs.

Direct costs are divided into two types: fixedand variable. Fixed costs are those that are pre-dictable, remain the same over time, and can becontrolled. Salaries, for example, are fixed costsbecause they remain relatively stable and can alsobe manipulated. The facility usually makesannual decisions to give employee raises, to freezesalaries, or to cut positions, thereby influencingthe budgeted amount for direct cost expendi-tures. In addition, mortgages, loan repayments,and the like are included as fixed costs.

Variable costs are those costs that, in the caseof healthcare organizations, depend on volume.The number of meals prepared, for example,depends on the patient census. From an educa-tional perspective, the demand for patient teach-

ing depends on the number and diagnostic typesof hospitalized patients. For example, if the vol-ume of cardiac bypass surgical patients is low,educational costs may be high due to the factthat intensive one-to-one instruction wouldneed to be offered to each patient admitted.Conversely, if the volume of bypass surgeries ishigh, it is less expensive to provide standardizedprograms of instruction via group teaching ses-sions for these cardiac clients. As another exam-ple, if demand or turnover of nursing staffincreases, the number of orientation sessions fornew employees would also increase in volume.Supplies, also a direct, variable cost, can changedepending on the amount and type needed.Variable costs can become fixed costs when vol-ume remains consistently high or low over time.

Indirect CostsIndirect costs are those costs not directly relatedto the actual delivery of an educational program.These include, but are not limited to, institu-tional overhead such as heating and air condi-tioning, lighting, space, and support services ofmaintenance, housekeeping, and security. Suchservices are necessary and ongoing whether ornot an educational session is in progress.

Hidden costs, a type of indirect cost, can nei-ther be anticipated nor accounted for until afterthe fact. Low employee productivity can producehidden costs. Organizational budgets are pre-pared on the basis of what is known and predic-table, with projections for variability in patientcensus included. Personnel budgets are based onlevels of staff needed (e.g., number of RNs, LPNsand nursing assistants) to accommodate the ex-pected patient volume. This is determined by anannual projection of patient days and how manypatients an employee can effectively care for on adaily basis. Low productivity of one or two per-sonnel on a nursing unit, for example, can have a

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significant impact on the workload of others,which, in turn, leads to low morale and employeeturnover. Turnover increases recruitment and newemployee orientation costs. In this respect, thecosts are appropriately identified as hidden.

In a classic description of understanding costs,Gift (1994) makes a point of distinguishingbetween costs—direct or indirect—and charges.As just described, direct and indirect costs arethose expenses incurred by the facility. Chargesare set by the provider, but they are billed to therecipient of the services. There may or may notbe a balanced relationship between costs andcharges. In the retail business, for example, ifcosts of raw materials are low, while charges forthe items, goods, or services are high, the retaileryields a profit. In the healthcare arena, not-for-profit organizations are limited by federal law asto the amount they can charge a client in relationto the actual cost of a service. In many instances,particularly as it relates to pharmaceutical goods,the actual cost to the facility is what the client ischarged. As such, the facility provides a servicebut realizes no financial profit (Kaiser FamilyFoundation, 2005).

Cost Savings, Cost Benefit, and Cost Recovery Patient teaching is mandated by state laws, pro-fessional and institutional standards, accreditingbody protocols, and regulations for participationin Medicare and Medicaid reimbursement pro-grams. However, unless it is ordered by a physi-cian, patient education costs are generally notrecoverable under third-party reimbursement asa separate entity. Even though the costs of edu-cational programs, for both patients and nursingstaff, are a legitimate expense to the facility, thesecosts usually are subsumed under hospital room

rates and are, therefore, technically absorbed bythe healthcare organization.

Hospitals realize cost savings when patientlengths of stay are shortened or fall within theallotted diagnostic related group (DRG) timeframes. Patients who have fewer complicationsand use less expensive services will yield a costsavings for the institution. In an ambulatory care setting such as an HMO, cost savings are real-ized when patient education keeps people healthyand independent for a longer period of time,which prevents high utilization of expensive diag-nostic testing or inpatient services. However, andperhaps most importantly, patient education be-comes even more essential when a pattern of earlydischarge is detected, resulting in frequent re-admissions to an agency. The facility comes underscrutiny by HCFA/CMS and may be penalizedeither through citation or loss of payment—inwhich case, cost savings becomes a moot point.

Cost benefit occurs when there is increasedpatient satisfaction with an institution as aresult of the services it renders, including edu-cational programs it provides such as childbirthclasses, weight and stress reduction sessions, andcardiac fitness and rehabilitation programs. Thisis an opportunity for an institution to capture apatient population for lifetime coverage. Patientsatisfaction is critical to the individual’s returnfor future healthcare services.

Cost recovery results when either the patient orinsurer pays a fee for educational services thatare provided. Cost recovery is realized throughthe marketing of health education programsoffered for a fee.

Under Medicare and Medicaid guidelines,reimbursement may be made for programs “fur-nished by providers of services to the extent thatthe programs are appropriate, integral parts inthe rendition of covered services which are rea-sonable and necessary for the treatment of the

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Program Planning and Implementation 43

individual’s illness or injury” (Kaiser FamilyFoundation, 2005). The key to success inobtaining third-party reimbursement is theability to demonstrate that as a result of educa-tion, patients can manage self-care at home andconsequently experience fewer hospitalizations.

To take advantage of cost recovery, hospitalsand other healthcare agencies develop and mar-ket a cadre of health education programs that areopen to all consumers in the community. Nomatter whether a client is charged in full or payson a sliding scale for these services, the Americanmentality is “if it costs something, it must beworth something.” Thus, fee-for-service pro-grams usually are well attended and result in rev-enues for the institution. The critical element, ofcourse, is not only the recovery of costs but alsorevenue generation. Revenue generation refers toincome realized over and above program costs,which can also be regarded as profit.

To offset the dilemma of striving for cost con-tainment and solvency in an environment ofshrinking fiscal resources, healthcare organiza-tions have developed alternative strategies forpatient education to realize cost savings, costbenefit, cost recovery, or revenue generation. Forexample, a preoperative teaching program forsurgical patients given prior to admission to thehospital has been found to lower patient anxi-ety, increase patient satisfaction, and decreasenursing hours during hospitalization (Wasson &Anderson, 1993).

Program Planning andImplementationThe key elements to consider when planning apatient education offering intended for genera-tion of revenue include an accurate assessmentof direct costs such as paper supplies, printing

of program brochures, publicity, rental space,and time (based on an hourly rate) required ofprofessional personnel to prepare and offer theservice. If an hourly rate is unknown, a simplerule of thumb is to divide the annual base salaryby 2080, which is the standard number of hoursworked by most people in the course of 1 year.

If the program is to be offered on the premisesof the facility, there may be no need to plan for arental fee for space. However, indirect costs suchas housekeeping and security should be proratedas a bona fide expense. Such a practice not onlyis good fiscal management, but also provides anaccounting of the contributions of other depart-ments to the educational efforts of the facility.

Fees for a program should be set at a levelhigh enough to cover the aggregate costs ofprogram preparation and delivery. If the intentof an education program is for cost savings tothe facility, such as provision of educationclasses for diabetics in the community to reducethe number of costly hospital admissions, thenthe aim may be to break even on costs. Theprice is set by dividing the calculated cost bythe number of anticipated attendees. If the goalis for cost benefit to the institution, success canbe measured by increased patient satisfaction(as determined by questionnaires or evaluationforms) or by an increase in the use of the spon-sor’s services (as determined by record keeping).If the intent is to offer a series of classes forsmoking cessation or childbirth to improve thewellness of the community and to generateincome for the facility, then the fee is set higherthan cost so as to realize a profit (cost recovery).

Over the course of a year, it is usually neces-sary for nurse educators to give an annual reportto administration of time and money spent andwhether such expenditures were profitable tothe institution in terms of cost savings, costbenefit, or cost recovery.

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Cost-Benefit Analysis andCost-Effectiveness Analysis In the majority of healthcare organizations, theeducation department bears the major respon-sibility for staff development, for in-serviceemployee training, and for patient educationprograms that exceed the boundaries of bedsideinstruction. Total budget preparation for thesedepartments is best explained by the experts inthe field. Fisher, Hume, and Emerick (1998),for example, address the need for staff develop-ment departments to engage in responsibility-centered budgeting (RCB), which also is referredto as activity-based management (ABM). Giventhe shift away from providing at-will servicesand toward greater demand for cost accounta-bility for educational programs, they propose atemplate for costing out programs that allowsstaff development departments to identify andrecoup their true costs while responding toincreased market competition.

There is no single best method for measuringthe effectiveness of patient education programs.Most experts in the field tend to rely on deter-mining actual costs or actual impact of pro-grams in relationship to outcomes by employingone of two concepts: cost-benefit analysis orcost-effectiveness analysis (Abruzzese, 1992).

Cost-benefit analysis refers to measuring therelationship between costs and outcomes.Outcomes can be the actual amount of revenuegenerated as a result of an educational offering,or they can be expressed in terms of shorterpatient stays or reduced hospitalizations for par-ticular diagnostic groups of patients. If, underDRGs or capitation methods of reimbursement,the facility makes a profit, this can be expressedin monetary terms. If an analysis reveals that aneducational program costs less than the revenue

it generates, that expense can be recovered bythird-party reimbursement, or that savings aregreater than costs to the facility, then the pro-gram is considered to be of cost benefit. Themeasurement of costs against monetary gains iscommonly referred to as the cost-benefit ratio.

Cost-effectiveness analysis refers to the impactan educational offering has on patient behavior.If program objectives are achieved, as evidencedby positive and sustained changes in behavior of the participants over time, the program issaid to be cost effective. Although behavioralchanges are highly desirable, in many instancesthey are less observable, less tangible, and noteasily measurable. For example, reduction inpatient anxiety cannot be converted into a gainin real dollars. Therefore, it is wise to analyzethe outcome of teaching interventions by com-paring behavioral outcomes between two ormore programs to identify the one that is mosteffective and efficient when actual costs cannotbe determined.

As difficult as it may be from the standpointof justice, the nurse educator must attempt tointerpret the costs of behavioral changes (out-comes) to the institution by conducting a cost-effectiveness analysis between programs. This canbe accomplished by first identifying and itemiz-ing for each program all direct and indirect costs,including any identifiable hidden costs. Second,it is necessary to identify and itemize any bene-fits derived from the program offering, such asrevenue gained or decreased readmission ratesthat can be expressed in monetary values. Resultsof these findings can then be recorded on a gridso that each program’s cost effectiveness is visu-ally apparent (see Figure 2–1).

Mitton and Donaldson (2004) suggest a non-vested team approach to an analysis of programeffectiveness for the purpose of determining theallocation or reallocation of valuable resources

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State of the Evidence 45

between and among services or programs. Thisapproach ensures the integrity of the total processof program evaluation. In addition to this rec-ommendation, the International Council ofNurses (ICN) published a position statement in2001 that, among other things, obligates nursesto demonstrate their value in promoting cost-effective, quality care by playing a leadership rolein program planning and evaluation, in policysetting, and in interactive networking on cost-effectiveness research, cost-saving strategies, andbest practice standards (Ghebrehiwet, 2005).

State of the EvidencePractice that is driven by evidence is defined asbeing “practice that is based on research, clini-cal expertise, and patient preferences that guidedecisions about the healthcare of individual

patients” (HPNA Position Paper, 2004, p. 66).In this chapter, the six ethical principles havebeen explicated in terms of their relationship topatient education, in particular, and to health-care services, in general.

Comparatively speaking, the application ofethics (known as applied ethics) to health care isa relatively recent phenomenon. Much evidencesuggests that the tried-and-true ethical princi-ples as well as a wide variety of ethical theoriesplay a highly significant role in shaping con-temporary healthcare delivery practices and deci-sion making. In our increasingly multiculturaland pluralistic society, the challenge is to be ableto address the vast array of biomedical ethicsissues confronting healthcare practitioners on adaily basis in a way that preserves an individual’srights but also protects the well-being of otherpersons, groups, and communities. The complex

Figure 2–1 Cost effectiveness grid.

Program

Direct $ $

$ $

$ $

Indirect

Hidden

$ $

$ $

Decreased readmissions

Revenue generated

I II

Costs

Benefits

Total

$ $

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and technological advances in health care havegiven rise to numerous questions about what isright or wrong, yet very few clear-cut or per-fectly right answers have been forthcoming.Numerous case studies, books, and articles onhow to deal with ethical dilemmas abound.They attempt to provide evidence for nursingpractice, including patient education, abouthow to deliver care in the most equitable andbeneficial manner possible.

Laws and standards that govern the role ofthe nurse as educator are firmly established andprovide the legal foundations and professionalexpectations in practice for the delivery of qual-ity patient care. Also well established is theimportance of documenting nursing interven-tions, but more research that provides evidenceof the frequency and amount of patient educa-tion nurses do daily on an informal basis thatnever gets recorded must be conducted. In addi-tion, although strategies exist for analyzing costeffectiveness and cost benefits as a means tostrengthen the value and accountability of thenurse educator to the client and to the employ-ing agency, more research evidence is needed tosubstantiate the importance of the educator’srole in influencing overall costs of care.

Further research needs to be conducted to de-termine, through comparative analysis, whichtypes of patient education programs are themost equitable, beneficial, and cost effective forpatients, nursing staff, the institution, and the

communities served. Evidence is scarce on theeconomics associated with various approaches toeducation and the value of the nurse educator’srole as it impacts on behavioral outcomes relatedto cost savings, cost benefit, and cost recovery.

SummaryEthical and legal dimensions of human rightsprovide the justification for patient educa-tion, particularly as it relates to issues of self-determination and informed consent. Theserights are enforced through federal and stateregulations and through performance standardspromulgated by accrediting bodies and profes-sional organizations for implementation at thelocal level. The nurse’s role as educator is legit-imized through the definition of nursing prac-tice as set forth by the prevailing nurse practiceact in the state where the nurse is licensed andemployed. In this respect, patient education is anursing duty that is grounded in justice; that is,the nurse has a legal responsibility to providepatient education and, regardless of their cul-ture, race, ethnicity, and so forth, all clients havea right to health education relevant to theirphysical and emotional needs. Justice also dic-tates that education programs should be de-signed to be consistent with organizational goalswhile meeting the needs of patients to be in-formed, self-directed, and in control of theirown health, and ultimately of their own destiny.

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References 47

Abernathy v. Sisters of St. Mary’s, 446 SW2d 559(MO1969).

Abood, S. (2001). The Bush regulatory agenda. American Journal of Nursing, 101(8), 22.

Abruzzese, R. S. (1992). Nursing staff development:Strategies for success. St. Louis, MO: Mosby.

American Hospital Association. (1975). Patient’s bill of rights. Chicago: Author.

American Hospital Association. (1992). A patient’s bill of rights. Retrieved March 27, 2007, fromhttp://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm

American Nurses Association. (1976). Code of ethics fornurses with interpretative statements. Kansas City,MO: Author.

American Nurses Association. (1978). Model nurse practiceact. Washington, DC: Author.

REVIEW QUESTIONS

1. What are the definitions of the terms ethical, moral, and legal, and how are they dis-tinct from one another?

2. Which national, state, professional, and private-sector organizations legislate, regulate,and provide standards to ensure the protection of human rights in matters of health care?

3. Which ethical viewpoint, deontological or teleological, refers to the decision-makingapproach that choices should be made for the common good of people?

4. With respect to ethical, moral, and legal obligations, how does the American HospitalAssociation’s Patient’s Bill of Rights compare to the American Nurses Association’s Codeof Ethics for Nurses With Interpretive Statements?

5. What are the six ethical principles that dictate the actions of healthcare providers indelivering services to clients?

6. Why are nurse practice acts so important to nurses in carrying out their roles andresponsibilities to the public?

7. What is the difference between the terms negligence and malpractice? 8. When was informed consent established as a basic tenet of ethics and what is the nurse’s

role in situations involving informed consent?9. What is meant by the legal term respondeat superior, and how does this term apply to

professional nursing practice?10. Why is documentation of professional nursing duties, particularly patient education,

so important in the provision of care by nurses? 11. What are four examples of direct costs and five examples of indirect costs in the provi-

sion of patient/staff education?12. What are the definitions of these terms: fixed direct costs, variable direct costs, indirect costs,

cost savings, cost benefit, cost recovery, cost-benefit analysis, and cost-effectiveness analysis?

References

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American Nurses Association. (1985). Code of ethics fornurses with interpretive statements. Kansas City, MO:Author.

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