LEGAL ETHIC OF NURSINGPROJECT BASED LEARNINGTRIGGER FOR STANDARD PRACTICE IN NURSING

Group 11. Novita Eka Saputri1050702001310012. Achmad Vindo G1050702001310023. Dadang Putrawansyah1050702001310034. A. Zahriar Badaruddin1050702001310045. Isa Ariyanti1050702001310056. Jurita Purnama Sari1050702001310067. Anggraeni Citra S.1050702001310078. M.Taufik Bachtiar1050702001310089. Alfat Ayu Marga10507020013100910. Shofi Khaqul Ilmy10507020013101011. Resti Lovita Nur10507020013101112. Arphido Prastyatama10507020013101213. Lailatul Purwasih Putri10507020013101314. Shindy Anggreini Putri10507020113100115. Arum Desi Pratiwi105070201131001

NURSING K3LN DEPARTMENTMEDICAL FACULTY OF BRAWIJAYA UNIVERSITYMALANG2011TRIGGER FOR PROBLEM SOLVING

CASE 1 :Trigger LEN FOR STANDARD PRACTICE

As a student nurse, you observe a fellow nursing student making a medication error. She is a good friend of yours and is visibly upset by her error. She is also afraid that if she tells the clinical instructor, she could get a poor grade for clinical, and she needs to have a good average to keep her scholarship. The client was not actually harmed by the med error, and your friend seems sufficiently upset by the incident to convince you that she wouldnt make a similar error again. What would you do?Keywords:1) Nurse studentNurse student is Individuals enrolled in a school of nursing or a formal educational program leading to a degree in nursing. Nursing students face a large number of ethical issues, both in their capacity as students and throughout their clinical training. Some issues are specific to nursing, and others are the kinds of issues all students face. Nursing students need to understand these issues, and to know where they can turn for assistance in making these difficult decisions.a) Educational EthicsMany students, both nursing and non-nursing, have ethical concerns such as cheating or plagiarism. It can be tempting to use an old paper from a former student or to take the answers to a test that is being offered by another class, for example. These kinds of ethical issues can plague a nursing student from the beginning of the educational process until graduation.Informed Consent : In the nursing field and clinical, nurses must secure an informed consent before a procedure is done on the patient. This is true for simple procedures such as IV installation as well as for surgical procedures. There is always the risk that the nurse might not know enough about the procedure to be qualified to obtain that consent. In addition, a nurse might be afraid to ask for consent when told to perform a procedure by the medical professionals instructing the nurse.Document Forgery : Forgery is a serious ethical issue. This involves not only copying a signature, but also signing a document without actually completing the process dictated in the paper. For example, a nursing student might be asked to write notes on a chart of a patient that he has not seen. Writing the notes on a chart after the fact also can be considered document forgery. This can cause difficulty in treating the patient later on, and it can cause people to believe the patient was seen at a time when he really was not seen.Crying Wolf : Ethical issues can come up for nursing students dealing with patients who "cry wolf," or complain of pain they don't really have. This becomes an ethical issue for the nurse as he struggles to decide whether to report these pains to his clinical trainer or to ignore them as attention-seeking behaviors. He also needs to decide whether these complaints are made for the purpose of seeking drugs, and he needs to know how to identify drug-seeking patients.Finding Help : It is important that nursing students remember that their instructors and peers either have been or currently are where they are. This allows the nursing student to discuss the ethical issues and moral conflicts that she might be experiencing. This can help the nurse develop a strong ethical base, and it also might help other nurses in similar situations.Nursing students are responsible for learning the tenets and skills required of nursing care, according to the National Student Nurses Association's Code of Academic and Clinical Conduct, which aims to lay the student's ethical and clinical foundation.b) The CodeThe code for nursing students calls on them to team up with faculty to promote top quality care; avoid practicing skills for which they lack training; abstain from mind-altering substances that impair judgment within an academic or clinical setting; support access to student drug- and alcohol-abuse rehabilitation programs; and uphold school policies that promote academic and clinical excellence.Learning Focus : Nursing students must constantly strive to increase their skills, according to the NSNA, which says that "a nursing student's commitment to evidence-based practice and to the health, well-being and safety of clients" is crucial because "the client willingly gives the nursing student their trust in her/his ability to provide nursing care in accordance with their clinical education objectives."Because health care is always evolving, nurses must "continue to educate themselves formally and informally throughout their careers to remain clinically competent to meet the health care needs of increasingly diverse client population across an ever-changing health care environment," the organization states in its interpretative statements about the code.Professional development--through lifelong learning and joining professional organizations for specialty nursing--is key to good nursing, according to the interpretive statements.

c) Similarities to Professional CodeThe NSNA--a 50,000-member nonprofit for students in associate, baccalaureate, diploma and generic graduate nursing programs--established the code to prepare student nurses for their careers, according to its website.The code, like similar canons at nursing colleges, takes some of its material from the American Nurses Association's Code of Ethics, which stresses respect for the patients through deference to their autonomy and respect for confidentiality.d) Campus AdvocateNurses must educate the community about public health concerns and threats to personal safety; they should also support initiatives that oppose homelessness, violence and other social ills, according to the professional code.Though relevant to nursing students who want to advocate for such causes within their larger community off campus, this guideline particularly requires nursing students to challenge college policies and environments that threaten health care. Nursing students should defer to the school's grievance policy to properly address the situation, the NSNA states.e) SignificanceNursing students are expected to follow the professional nurses' code, in addition to their own, because upholding these standards ensures "accountability and optimal care for their patients," says the University of Texas at Arlington's School of Nursing Code of Ethics. Such behavior enables nursing students to maintain the public's trust and respect, according to the university.

2) Clinical instructorNursing instructors teach patient care to nursing students in classroom and clinical settings. They demonstrate care methods and monitor hands on learning by their students. They instruct students in the principles and applications of biological and psychological subjects related to nursing. Some nursing instructors specialize in teaching specific areas of nursing such as surgical or oncological nursing.Nursing instructors may be full professors, assistant professors, instructors, or lecturers, depending on their approximately 41,000 nursing instructors employed in the United States.The duties of clinical instrustor are develops and executes a teaching curriculum for nursing students. A nursing instructor will explain specifics about the job to the students so they are prepared to work with patients in clinical settings. According to career planner, a nursing instructor lectures students, conducts and supervises laboratory work, issues assignments, and directs seminars and panels. As a nursing clinical instructor, it's important to be patient and supportive of the students while pushing them to learn as much as they can while in the classroom so they can perform well in the clinical setting.In a clinical learning environment, instructors work with students and faculty to ensure the continued education of aspiring nurses, health practitioners and service providers. This position requires instructors to have a love of the profession for which they provide instruction along with an appreciation of academics.In addition, clinical instructors conduct nursing interventions and observe medical, surgical and allied health treatments to facilitate workplace learning while preparing, administering and grading examinations to determine student performance and achievement.

3) Medical errorAny incorrect or wrongful administration of a medication, such as a mistake in dosage or route of administration, failure to prescribe or administer the correct drug or formulation for a particular disease or condition, use of outdated drugs, failure to observe the correct time for administration of the drug, or lack of awareness of adverse effects of certain drug combinations. There are many possible causes of medical error:a) Communication errorsb) The increasing specialization and fragmentation of health carec) Human errors resulting from overwork and burnoutd) Manufacturing errorse) Equipment failuref) Diagnostic errorsg) Poorly designed buildings and facilities

Instead of that, there are many possible types of medication errors:a) Incomplete patient informationb) Unavailable drug informationc) Miscommunication of drug ordersd) Lack of appropriate labeling as a drug is prepared and repackaged into smaller unitse) Environmental factors, such as lighting, heat, noise, and interruptions.

To protect the client from medication errors, nurses have traditionally used as a guideline the five rights of drugs administration :

a. Right DrugThe nurse should:1. Check the label when removing the drug container from the clients medication drawer. 2. Check the drug when removing it from the container.3. Check the drug before returning it to the clients medication drawer.

b. Right doseThe nurse must know how to reduce the risk of errorby correctly calculating doses and having them double-checked before administration. To prepare scored or crushed medications, the nurse should make sure scored tablets are broken evenly. This practice will prevent overdosage or underdosage of a medication.

c. Right clientThe nurse should correctly identify the client by asking the client to state his or her full name and checking the clients identification armband.

d. Right routeThe nurse should consult the health care practitioner whenever a route is not identified in the prescription, when the route indicated differs from the recommended one, or when the nurse questions the choice of route prescribed. For example, the nurse should not substitute an oral medication for an intra-muscular medication simply because the oral medication is available and the intramuscular one is not.

e. Right timeNurses are responsible for knowing why a medication is ordered on a certain schedule and for following that schedule as closely as possible. To maintain the drugs effect, the nurse has to give the medication in a timely manner.Causes of medication error may also include difficulty in reading handwritten orders, confusion about different drugs with similar names, and lack of information about a patient's drug allergies or sensitivities. When the nurse is in doubt, administration of a drug should be delayed until specifically authorized by a physician.

4) Standard practice in nursingA set of guidelines for providing high-quality nursing care and criteria for evaluating care. Such guidelines help assure patients that they are receiving high-quality care. The standards are important if a legal dispute arises over the quality of care provided a patient.

Learning Objectives:Students will be able to: Identify the medication error Explain the terms Nursing standard and patient safety Discuss the nursing standard act based on INNA and ICN

As a nurse student, what would you do in relation to your friend have medical error? On the other hand, nurse must implement base from standard practic.

Explanation the question base from framework of solving the standard practiceand medical error follows:1. Develop from baseline dataa. Nursing student 1 making a medication errorb. Nursing student 1 is a good friend of minec. Nursing student 1 hasnt told the clinical instructor yet related to the medication errord. Nursing student 1 needs to have a good average to keep her scholarshipe. The client was not actually harmed by the med errorf. Nursing student 1 seems sufficiently upset by the incidentg. What should I do (as nursing student 2) to nursing student 1?2. Identify the conflict because the situation

Nursing student 2

Conceptual map is explained that the student of nursing is the responsibility of the clinical instructor. While a student of nursing which is responsible for a client have done of medication errors. Student nursing two of my own to serving as a student of nursing 1 and then indirectly involved in this. In accordance with the opening of the code of conduct by management & nurse Indonesia, which is associated with the nurse and peer relationships, Nurses have always maintained good relations with other nurses and other health workers, and maintain harmony in the workplace atmosphere and achieve an overall health care (PPNI,2011)Therefore, in the case as friends of my nursing students still have to be good friends. To explain about what things should I do in terms of "good friends" I'll explain in the "Problem Solving".Based on these cases, it can be seen from various perspectives, both from the viewpoint of WHO nursing students make medication errors, clinical instructor, and we as a student nurse who was a friend of a nursing student and witnesses. In this case one of the parties should not judge or justify a particular party because we are required to think critically, logically and objectively.a. Nursing student 1Positive view : Nursing student 1 seems sufficiently upset by the incident that she was making the medication error. Its indicate that the nursing student will not repeat mistakes. She still knows her position and what mess she had done, so the dissappointment feeling she had indicates her responsibility as nurse.Negative view : Nursing Student 1 was too scared and selfish to the client, because just thinking about the future, as she could get bad grades for clinical, and she needs to have a good average to maintain the scholarship. Although medication errors that have been made not to cause harmful effects for the client, but still, her actions should be dealt with firmly. Assertive action by which I mean in the form of punishment, but it depends on the decision of clinical instructor in charge of the (nursing students) us. In terms of knowledge-based practice that she has, nursing student 1 may have got science in terms of intervention for a client but, because of her status as still as a student, so she is less able to decide was the right information and resources, improve patient care and achievement of desired patient outcomes. then she must learn more in future. responsibility & accountability for nursing practice: and for maintaining competence by continual learning(ICN; 2006) In terms of standards of nursing practice conducted by student 1, it was clear that she is still not good and still have much to learn. As said about Provision of Services to the Public, the nurses provide nursing services in collaboration with the client, significant others and other health professionals (International Council of Nurses; 2006), so that he may think fit for the client's decision after health professionals collaborate with others .

b. Clinical instructorPositive view : In this case, it didnt clearly explained about the actual role of clinical instructor. Making it very difficult to identify the positive side.Negative view : As the party responsible for student nurses, clinical instructor lack of supervision to the nurse student. He/she must observe their actions, primarily related to the provision of intervention for the client.

3. Creating an alternative action on the planned course of action and consider the outcomes or consequences of such actionIn accordance with the opening of the code of conduct by Indonesian Nursing Association, which is associated with the nurse and peer relationships, "Nurses always maintain good relations with fellow nurses as well as with other health personnel, and maintaining harmony in the workplace as well as in achieving the objectives of service health "(INNA, 2011) Therefore, in the case as friends of the nursing students I still have to be good friends.

So what should I do in terms of "being a good friend" is giving advice to a student of nursing to inform about the medication errors that have been made to the client to her clinical instructors. It is very important although the effect is not harmful to the client, for students of nursing 1 does not make the same mistakes or worse mistakes in the future. NURSE TAKES appropriate action tosafeguard individuals, families, and communities when their health is endangered by a co-worker or any other person (ICN;2006)If a student notify the instructor of clinical nursing ,it is then likely that they exist:

Clinical Instructor gets angry - > reduce the grade of nursing students clinical instructor is not angry - > forgive, and to offer solutions for the medication errors that have been out of nursing students

4. Determine who the appropriate decision makers

Appropriate decision maker in accordance with this case is the nursing student who has committed medication errors. Although it can affect the value or scholarships, she still must take responsibility for his actions because it involves human life. Nursing student 1 should informed to the clinical instructor about her medication error.As for clinical instructor, he/she was the one who has the authority to nurse student. But he/she also has someone in higher position than him/hers (e.g. professor,lecturer) who can punish or fire the clinical instructor as the result of his/her lack of supervision to the nurse student.

5. Defining of duty nurse

Duty is an obligation created either by law or contract or by any voluntary action. It is the first element that must be proved for malpractice as it arises from the nurse-client relationship. A nurse do their profession to fulfill the duties they have such as some points below: Perform all nursing duties in accordance with the state Nursing Act Perform routine nursing care to assigned patients Monitor patient progress and identifies any changes in status, acting on those changes to insure patient comfort and safety Actively demonstrate a working knowledge of nursing theory, techniques, principles, and practice in order to holistically care for the patient Must be able to perform various sensory requirements in order to assess and treat the patient accurately. Obedient to the nursing code of ethics. Nurse must fullfill the standard practice in nursing whenever he/ she works

6. Making decisionsBased on data that have been identified above, now well make a decision about what should we do related with this case. As on the mentioned info on the case, the fault nurse is looked so upset and afraid. These kind of situation will make we, as her friends on dilemmatic situation.Here are the factors that causes dilemma :1. The error medication is not harmfully effect through the patient2. She is our good friend3. It was her first time do medication error4. She should keep her mark related with her scholarshipand cause of those factors, well explain the positive side (tell the instructor) and the negative side (not tell the instructor).From the first factor, The error medication is not harmfully effect through the patient we may be think that it should not be reported since the error is not affecting the patients because its not harmful. But, its completely wrong. As we can compare, it look alike a thief who stole something. Once we let this thief steal, another day they will be do the same. Same with this case, once we let she run from this case, another day when she do the same thing, she will do the same. So that is why we should tell the instructor about this. It is not about the effect that shown on patient, but about the obedience to the rules.The second factor She is our good friend . If we pretend that we did not know anything bout what was happened, we are not a good friend for her. As a good friend, we should make it as a good chance to affect her to complaining her fault. And as a good friend, we should tell her which one is right and which one is wrong. We should capable to give a persuasive explanation to her in order to make sure that she can tell the instructor by herself and bravely tell her fault. If we do not tell the instructor, we are a liar, cause we hide the truth, and its not suitable with the code of ethic. It also called and immorality cause we are hiding the truth.The third factor is It was her first time do medication error. Even it was her first error, it does not matter cause once she done a fault. It still called a fault and it is irreversible. Same like the first factor we cant let it go. It will be good if on her first fault, she feel guilty and do wont to do it again someday. It can be a good motivation for her. Because it will be a good experience for her to work carefully.The last factor is She should keep her mark related with her scholarship. She was worried bout her mark related with her scholarship. But its a selfish act that done by her. She just pushed her rights and loose the patients right. Patients should get a satisfaction during the medication. But what she did is not giving satisfaction through the patients. As a professional nurse, those kind of act is should not be done. If she tell the instructor, we never know what is exactly will happen. The instructor may be give a positive mark or tolerate it cause she is still a student. So the best way is just tell the instructor.

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