Are nurses abdicating their obligations? Lois C Crooks, RN
Lois C Crooks, R N , is director of operating rooms, George Washington Uni uersi ty Medical Center, Washington, DC. She received her B S E d degree from Washington Technical Institute. Mrs Crooks presented this paper at the 1975 Congress.
t is necessary to pause occasionally while pursuing a career in nursing and reflect on where nursing has been, where it is going, and what its goals are. The purpose and image of nursing have changed appreciably over the past 120 years and promise to continue to change with the rapid emergence of a n increasingly complex society. Nurses and professional nursing are defined by several sources, such as state licensing legislation, nurse practice acts, and professional organizations. Florence Nightingale’s pledge describes nurses as “those who would with loyalty endeavor t o aid the physician in his work and devote themselves to the welfare of those committed to their care.” All these definitions can be summarized to say professional nurses have accepted the moral and legal obligation to serve as the patient’s advocate. It is the responsibility of each individual nurse to identify specifically how she will fulfill this role. However, certain factors influencing this decision remain constant and must be the basic consideration of every nurse, whether she practices in the clinical area, research, education, administration, or the extended role which remains as yet undefined by law in most states. These factors are: (1)the patient, (2) the law, and (3) moral obligation. As a n individual, each nurse must interpret moral obligation, but as a professional nurse, she needs no soul searching or intellectual exercise to determine her legal responsibility. That has been and continues to be determined for nurses. It is the issue of professional responsibility and the resulting legal implication of abdicating this responsibility that I will address. More specifically, five areas of nursing responsibility must be recognized and fulfilled if nurses are to fulfill a moral and legal obligation t o serve as the patient’s advocate. The first responsibility is providing quality patient care by insuring adequate staffing. If you are about to counter “that’s the responsibility of the administration or the supervisor,” YOU may be surprised to learn
AORN Journal, October 1975, V o l 2 2 , N o 4
523
that you are also responsible for adequate staffing and may be considered negligent if you fail to try to effect a change in adverse staffing conditions. Traditionally, it is the supervisor who assesses the staffing needs of a unit and provides accordingly. In the operating room, minimal staffing needs require two nursing personnel to every patient. This is a reversal of the unit staffing pattern and may well send a budget-conscious director or administrator into orbit. Although expensive and a t times difficult to achieve, it is a minimal need to provide adequate nursing care. Many supervisors feel they should not have to fight constantly for bare necessities, and it is easy to sympathize with them. Why should any nurse, supervisor, or staff nurse have t o wage a battle with an employer to provide the kind of care all (ie, Joint Commission for Accreditation of Hospitals, American Nurses’ Association, AORN, and every conscientious nurse) acknowledge as necessary. We all know that idealism and perfection are low priorities when money is a n issue. Administration is apt to allow you t o “make do” if you will. If you can relate to a situation where one nurse circulates between two rooms, call is added to a double shift, new personnel without orientation are utilized as staff, and the pace is unbroken by lunch or coffee break, then you have experienced a compromise. Can we afford these compromises? The law says we cannot. The Regan Report clearly states that t o accept understaffing is a failure on the part of a nurse to understand her personal professional responsibility, one that may involve her in a lawsuit as the defendant. What is the recourse? Nonacceptance! Staffing can logically be considered the re-
524
sponsibility of the nursing supervisor, but should the person charged with this responsibility be ineffective, then it becomes the responsibility of the individual nurse to bring the condition to the attention of the hospital administration or medical director and insist on adequate staffing to provide quality care. Write, explain, justify needs and do it in duplicate retaining a copy. Verbal communication often is forgotten or ignored; nothing is as effective in jogging the memory or substantiating one’s concern as a memo. Negligence is a cruel label to attach to a nurse trying to do the work of two, but it is exactly what you will be considered if you accept understaffing and a n accident results. I have used the word negligence as defined by lawnegligence is simply carelessness. The elements of negligence are: 1. a standard of care, under the circumstances 2. a forseeability of harm if that standard is not met 3. a failure to meet the standard of care 4. the fact that failing to meet the standard has caused harm to the patient. The standard is determined by deciding what the reasonably prudent person would have done under similar circumstances. The reasonably prudent person is, of course, hypothetical-a compendium of peer behavior under similar circumstances. Following closely behind the responsibility to provide adequate numbers of personnel is the responsibility to determine appropriate roles for personnel. As a leader, the supervisor should be the first to recognize and insist upon appropriate roles, but if she fails to meet this responsibility, each of us, as a professional, can and
AORN Journal, October 1975, Vol22, N o 4
t is temptation to scrub . . . but you cannot
Iafford this luxury.
must insist on safe, quality care for every patient. What do I mean by the appropriate role? Simply, occupying the position on the team for which you are best suited. Not many specific guidelines exist. Even those that do exist can be ignored for a time. For the most part, supervisors are charged with the responsibility of providing adequate staffing. This does not provide us with the comfort of a you may or you may not; it calls upon judgment and conscience. If you are assigned to scrub while a technician circulates or worse, if you elect to scrub while a technician circulates, you are not playing a n appropriate role. It is a temptation to scrub for an interesting case or for a favorite surgeon, but you cannot afford to indulge yourself in this luxury if the staffing ratio is one nurse to one technician in your OR. You are the professional nurse charged with the responsibility of caring for the patient. Your education has prepared you to assess patient needs, make necessary nursing judgments, and carry out necessary procedures. The technician, by standard definition, is the individual prepared to carry out technical procedures a n d assist t h e professional nurse and physician in caring for the patient requiring surgical intervention. Can it be clearer where
your responsibility lies? I do not mean to cast aspersion on the value of technicians as a part of the OR team. Nor do I minimize the problem that can occur when, after years of permitting technicians to emulate the role of the professional nurse, supervisors relegate them to the role of scrub personnel. I have no formula for avoiding unrest. Each supervisor must resolve this problem within the unique circumstances of her own institution and the framework of her own conscience. The US Department of Health, Education, and Welfare (HEW) has laid down specific regulations that do not rely on personal judgment or conscience. Institutions receiving Medicaid and Medicare funds must recognize and conform. Technicians are to be used a s scrub personnel only. The less stringent JCAH recommendations make it necessary to rely on individual judgment to provide adequate staffing. For some supervisors, this may be a n opportunity to ignore flagrantly the guidelines provided by HEW and AORN and open the door to perpetrating the practice of placing two people in each OR instead of two competent team members filling appropriate roles. If it does, then I can only admonish those individuals to reevaluate their qualifications to be in positions of authority. Ultimately, the long arm of justice will touch them, but un-
AORN Journal, October 1975, V o l 2 2 , No 4
525
fortunately harm will come to a patient first. Assigning personnel is the responsibility of the supervisor who is considered competent to make such judgments based on her education, experience, and familiarity with state, federal, and institutional regulations. She cannot be considered liable merely because the person t o whom she assigns duties is negligent and causes harm t o a patient, but she can be held personally liable for negligence as a supervisor if she assigns a person to a task for which they are not competent. In this instance, competence becomes both a matter of individual judgment and of regulations imposed by agencies such as HEW. In conjunction with the responsibility to provide an adequate number of personnel appropriately assigned, there is a responsibility to provide personnel qualified to do the job. Basic qualifications are frequently determined by the personnel office as a result of reviewing a n application for employment. This is adequate to determine the basic education, previous employment (not experience), and to filter out the obvious undesirables. However, the custom of interviewing and hiring nursing personnel in the personnel department leaves much to be desired. The maximum assessment one is able to make, based on the standard personnel form, is: 1. Basic education: There is no information to describe exposure to a special area, the quality of instruction, or the suitability of the applicant. 2. Previous position: This is not synonymous with previous experience. There is considerable difference. It is impossible to assess the actual experience of the applicant by means of the usual written application form.
526
By compiling data, one can arrive a t years of employment, but is this significant data? What significance is there in the fact that a n individual has one year, two years, or ten years OR experience, unless there is specific data about the kind of experience? Can qualifications be adequately determined on paper or by a personnel officer? The OR supervisor is the best person to determine the ability of a n applicant to meet the needs of her department. By means of interview, she can gain multiple clues to experience as opposed to previous jobs, job knowledge as opposed to basic education, suitability as opposed to availability. The OR supervisor can put these clues together and create a profile of the applicant. It is a time-consuming task, but it is a responsibility. The reference form is another standard procedure of dubious value. Certainly, i t identifies the very bad and the very good, but what about those in between? How many supervisors under admonition from the personnel department to be careful and in fear of becoming involved in a legal action are willing t o tell the whole truth? Once the employee has left her department, relief and indifference may replace conscience, and the supervisor will fill out the confidential reference form right down the middle. How many of you are currently burdened with a staff member who is mediocre with borderline competency because someone was reluctant to be forthright? If you don’t have input to the hiring of your staff, you have abdicated this responsibility to the personnel department. Adequate supplies and equipment are needed to care for the patient properly. Again, there are no rigid guidelines or specific rules. The umbrella of adequate care is still hover-
AORN Journal, October 1975, V o l 2 2 , No 4
S
tandards are established to render better care, not avoid prosecution.
ing over us. Some years ago, the law in many states looked sympathetically on the private hospital and excused it from liability under the doctrine of charitable immunity. It was thought that the assets or property of such a n institution were held in trust for the community and could not be sacrificed to benefit an individual plaintiff. Government or public hospitals were even more sacred because the care, however inadequate, was still free. These laws no longer exist in most states. When an institution opens its doors to the public, it is in essence telling the public “you may come here and expect to receive adequate care given by qualified personnel.” Standards of care have been established to render better care, not to avoid prosecution. These standards have been established by organizations such as JCAH, the federal government, professional organizations, and individual states. Although selfimposed, these standards are being looked to as guidelines for legal standards. Significantly, the trend in hospital liability law is toward national standards of care. The “local community standard” is disappearing. No longer is it possible for a n institution to be excused from the obligation to provide comprehensive quality care because it is small or rural. The hospital is recognized as a community
health facility from which the public is entitled to receive standard care, regardless of size, location, or governing body. Part of standard care is the availability of essential equipment to support medical and nursing judgments. Obtaining and maintaining operating room equipment is a voluminous problem facing every OR supervisor. Some companies are fiercely independent, especially when they hold the key or franchise to supply and repair a particular item. Instrument and equipment budgets are adversely affected by escalating costs. Purchasing departments, vendors, and delivery services appear to unite against OR supervisors when something is needed in a hurry. However, the responsibility to provide quality care is still there. Do you notify the posting clerk when essential pieces of equipment are out for repair? Do you refuse to book five cases requiring electrocautery units when you know the department has only four in operation? Do you continue to request and justify requests for equipment necessary to give adequate care? Do you look for a n alternative when your request is refused, or are you just tired of talking to a brick wall, or, even more unfair, being harrassed by that surgeon with the fifth case requiring a n electrocautery? Stick to your guns. You are obli-
AORN Journal, October 1975, V o l 2 2 , No 4
521
gated to maintain a standard of safe quality care in your area of responsibi1ity . The fifth area of responsibility is the most difficult for most nurses to adjust to, especially nurses who emerged in the era of nurses being “doctor’s helpers.” This is the responsibility to report any unusual or obviously substandard care by a physician or another nurse. Peer evaluation is relatively new in the nursing profession. Monitoring care given by a physician is so new as to send the fear of reprisal through many nurses. The role of the nurse as the patient’s advocate emerged long after the role of the nurse as an inferior assistant to the physician. It may take a bit more time t o establish guidelines for behavior in this new role. Nurses know by their education and experience what constitutes usual precaution and standard care, and it behooves them to note any observation that indicates either is not being carried out. If there is a flagrant violation of good or standard patient care, it is both a moral and legal obligation to bring this to the attention of the nursing administration, chief of surgery, or medical director of a n institution. If you fail to do so, there may be repercussions far greater than the wrath of an irate physician. In the case of Darling vs Charleston Community Memorial Hospital, Illinois, 1965, a football player was admitted to the emergency room with a fractured leg. He was treated by the doctor on emergency room call, a general practitioner who placed the leg in a cast. Over a period of days of hospitalization, the patient complained of agonizing pain in the leg. His toes became swollen, dark, and eventually insensitive. The doctor visited daily and apparently was satisfied with the pa-
528
tient’s progress. The nursing staff noted the complaints, the change in appearance of the toes, and ultimately a foul odor arising from the cast. Subsequently, the young man’s leg was amputated as a result of impaired circulation and gangrene. What kind of blinders were the nurses wearing to prevent them from seeing their obligation to do something definitive t o help the patient? Any registered nurse should recognize the symptoms of impaired circulation. To assume otherwise is to question seriously if nurses are properly prepared to meet the simplest nursing responsibility. In this case, the nurses escaped prosecution. The patient brought charges against the hospital and the physician. Both were found liable. The patient had every right to bring charges against the nurses, but nurses were not yet being held legally accountable for their actions in many instances. Today, those nurses would probably be named in such a suit, and rightly so. I am not suggesting that a nurse is a monitor of medical care. Surgeons have their responsibilities and their ethics. But it is the responsibility of nurses to make their observations known and in that way to be accountable and to insure that all others concerned with patient care are accountable for the quality of care given. If you can honestly say you have been prudent in carrying out this responsibility, then you are exempt from the reach of both guilty conscience and the law. Responsibility is one regulating mechanism enabling us to live as social beings. The nature of one’s responsibility is dependent upon one’s role in society. Traditionally, mothers are responsible for infants, fathers for households, nurses for patients. In the operating room, nurses have accepted
AORN Journal, October 1975,V o l 2 2 , N o 4
the responsibility for caring for the acutely ill and highly dependent patient. It is not, however, the magnitude of the responsibility that determines the success of a person as a social being, but rather it is the manner in which that person fulfills his responsibility. Are nurses abdicating responsibility? Yes, some are, through ignorance of those responsibilities and others through apathy. However, the vast majority are simply struggling with the task of identifying their responsibility and educating themselves regarding 1egal obl iga ti on. If you are guilty of abdicating responsibility because you are apathetic, I hope I have made you uncomfortable. Professional nurses have come a long way since Florence Nightingale recruited her first "nurse" from the slums of London. Professional nurses cannot jeopardize the results of 120 years of upward struggle by condoning apathy, excusing ignorance, or ignoring indifference. 0
References Benedikter, Helen. "JCAH standards: Why the trauma?" AORN Journal, 14 (September 1971). Carroll, Walter. "Joint Commission myth-(and the reality.)."AORN Journal, 14 (September 1971). Gouge, Ruth. "OR nurses face potential liabilities." AORN Journal, 20 (October 1974). Regan, William. The Regan Report on Nursing Law. 14, No 12, Regan, 1973. Roberts, Bruce. "Accreditation and legality." AORN Journal, 14 (September 1971). Springer, Eric. Nursing and the Law. Health Law Center, Pittsburgh, 1970. US Department of Health, Education, and Welfare Social Security Administration. Conditions of participation: Hospitals, federal health insurance for the aged. Code of Federal Regulations, Title 20, Chapter 111, Part 405.
New PSROs funded in 49 areas More than $21 million have been awarded to physician organizations for the initiation, planning, or support of medical review of federally financed health care by the US Department of Health, Education, and Welfare (HEW). The Professional Standards Review Organization (PSRO) legislation enacted by Congress in 1972 authorizes qualified physician groups to carry out peer review to assure that hospital and other medical care paid for by the Medicare, Medicaid, and Maternal and Child Health programs is medically necessary, is provided in the most appropriate health care setting and meets local standards of medical quality. Forty-nine PSROs, having successfully completed a year of planning activities, will begin to perform review of care provided in hospitals in the areas covered by the PSROs. The PSRO law requires that such groups operate on a conditional basis for up to two years, following which the HEW secretary may designate them as being fully operational. The 49 new conditional PSROs join 14 other comparable organizations in 12 states that have been in operation during the past year. Membership in the PSRO is open to all practicing physicians of medicine and osteopathy in its area, and the 63 conditional PSROs have memberships that range from approximately 30 to 90 percent of the physicians in their areas. In addition, federal PSRO planning funds have been awarded to 16 new physician organizations in 1 1 states. These groups will begin a year of start-up activities to eventually qualify to begin PSRO review on a conditional basis. To provide technical and professional assistance to multiple PSROs in certain of the nation's larger states, HEW also funded statewide PSRO support centers in Massachusetts,Connecticut, New York, New Jersey, Pennsylvania, Maryland, Virginia, North Carolina, Missouri, Ohio, Indiana, Michigan, and California.
AORN Journal, October 1975, Vol 22, N o 4
529
Lois C Crooks, R N , is director of operating rooms, George Washington Uni uersi ty Medical Center, Washington, DC. She received her B S E d degree from Washington Technical Institute. Mrs Crooks presented this paper at the 1975 Congress.
t is necessary to pause occasionally while pursuing a career in nursing and reflect on where nursing has been, where it is going, and what its goals are. The purpose and image of nursing have changed appreciably over the past 120 years and promise to continue to change with the rapid emergence of a n increasingly complex society. Nurses and professional nursing are defined by several sources, such as state licensing legislation, nurse practice acts, and professional organizations. Florence Nightingale’s pledge describes nurses as “those who would with loyalty endeavor t o aid the physician in his work and devote themselves to the welfare of those committed to their care.” All these definitions can be summarized to say professional nurses have accepted the moral and legal obligation to serve as the patient’s advocate. It is the responsibility of each individual nurse to identify specifically how she will fulfill this role. However, certain factors influencing this decision remain constant and must be the basic consideration of every nurse, whether she practices in the clinical area, research, education, administration, or the extended role which remains as yet undefined by law in most states. These factors are: (1)the patient, (2) the law, and (3) moral obligation. As a n individual, each nurse must interpret moral obligation, but as a professional nurse, she needs no soul searching or intellectual exercise to determine her legal responsibility. That has been and continues to be determined for nurses. It is the issue of professional responsibility and the resulting legal implication of abdicating this responsibility that I will address. More specifically, five areas of nursing responsibility must be recognized and fulfilled if nurses are to fulfill a moral and legal obligation t o serve as the patient’s advocate. The first responsibility is providing quality patient care by insuring adequate staffing. If you are about to counter “that’s the responsibility of the administration or the supervisor,” YOU may be surprised to learn
AORN Journal, October 1975, V o l 2 2 , N o 4
523
that you are also responsible for adequate staffing and may be considered negligent if you fail to try to effect a change in adverse staffing conditions. Traditionally, it is the supervisor who assesses the staffing needs of a unit and provides accordingly. In the operating room, minimal staffing needs require two nursing personnel to every patient. This is a reversal of the unit staffing pattern and may well send a budget-conscious director or administrator into orbit. Although expensive and a t times difficult to achieve, it is a minimal need to provide adequate nursing care. Many supervisors feel they should not have to fight constantly for bare necessities, and it is easy to sympathize with them. Why should any nurse, supervisor, or staff nurse have t o wage a battle with an employer to provide the kind of care all (ie, Joint Commission for Accreditation of Hospitals, American Nurses’ Association, AORN, and every conscientious nurse) acknowledge as necessary. We all know that idealism and perfection are low priorities when money is a n issue. Administration is apt to allow you t o “make do” if you will. If you can relate to a situation where one nurse circulates between two rooms, call is added to a double shift, new personnel without orientation are utilized as staff, and the pace is unbroken by lunch or coffee break, then you have experienced a compromise. Can we afford these compromises? The law says we cannot. The Regan Report clearly states that t o accept understaffing is a failure on the part of a nurse to understand her personal professional responsibility, one that may involve her in a lawsuit as the defendant. What is the recourse? Nonacceptance! Staffing can logically be considered the re-
524
sponsibility of the nursing supervisor, but should the person charged with this responsibility be ineffective, then it becomes the responsibility of the individual nurse to bring the condition to the attention of the hospital administration or medical director and insist on adequate staffing to provide quality care. Write, explain, justify needs and do it in duplicate retaining a copy. Verbal communication often is forgotten or ignored; nothing is as effective in jogging the memory or substantiating one’s concern as a memo. Negligence is a cruel label to attach to a nurse trying to do the work of two, but it is exactly what you will be considered if you accept understaffing and a n accident results. I have used the word negligence as defined by lawnegligence is simply carelessness. The elements of negligence are: 1. a standard of care, under the circumstances 2. a forseeability of harm if that standard is not met 3. a failure to meet the standard of care 4. the fact that failing to meet the standard has caused harm to the patient. The standard is determined by deciding what the reasonably prudent person would have done under similar circumstances. The reasonably prudent person is, of course, hypothetical-a compendium of peer behavior under similar circumstances. Following closely behind the responsibility to provide adequate numbers of personnel is the responsibility to determine appropriate roles for personnel. As a leader, the supervisor should be the first to recognize and insist upon appropriate roles, but if she fails to meet this responsibility, each of us, as a professional, can and
AORN Journal, October 1975, Vol22, N o 4
t is temptation to scrub . . . but you cannot
Iafford this luxury.
must insist on safe, quality care for every patient. What do I mean by the appropriate role? Simply, occupying the position on the team for which you are best suited. Not many specific guidelines exist. Even those that do exist can be ignored for a time. For the most part, supervisors are charged with the responsibility of providing adequate staffing. This does not provide us with the comfort of a you may or you may not; it calls upon judgment and conscience. If you are assigned to scrub while a technician circulates or worse, if you elect to scrub while a technician circulates, you are not playing a n appropriate role. It is a temptation to scrub for an interesting case or for a favorite surgeon, but you cannot afford to indulge yourself in this luxury if the staffing ratio is one nurse to one technician in your OR. You are the professional nurse charged with the responsibility of caring for the patient. Your education has prepared you to assess patient needs, make necessary nursing judgments, and carry out necessary procedures. The technician, by standard definition, is the individual prepared to carry out technical procedures a n d assist t h e professional nurse and physician in caring for the patient requiring surgical intervention. Can it be clearer where
your responsibility lies? I do not mean to cast aspersion on the value of technicians as a part of the OR team. Nor do I minimize the problem that can occur when, after years of permitting technicians to emulate the role of the professional nurse, supervisors relegate them to the role of scrub personnel. I have no formula for avoiding unrest. Each supervisor must resolve this problem within the unique circumstances of her own institution and the framework of her own conscience. The US Department of Health, Education, and Welfare (HEW) has laid down specific regulations that do not rely on personal judgment or conscience. Institutions receiving Medicaid and Medicare funds must recognize and conform. Technicians are to be used a s scrub personnel only. The less stringent JCAH recommendations make it necessary to rely on individual judgment to provide adequate staffing. For some supervisors, this may be a n opportunity to ignore flagrantly the guidelines provided by HEW and AORN and open the door to perpetrating the practice of placing two people in each OR instead of two competent team members filling appropriate roles. If it does, then I can only admonish those individuals to reevaluate their qualifications to be in positions of authority. Ultimately, the long arm of justice will touch them, but un-
AORN Journal, October 1975, V o l 2 2 , No 4
525
fortunately harm will come to a patient first. Assigning personnel is the responsibility of the supervisor who is considered competent to make such judgments based on her education, experience, and familiarity with state, federal, and institutional regulations. She cannot be considered liable merely because the person t o whom she assigns duties is negligent and causes harm t o a patient, but she can be held personally liable for negligence as a supervisor if she assigns a person to a task for which they are not competent. In this instance, competence becomes both a matter of individual judgment and of regulations imposed by agencies such as HEW. In conjunction with the responsibility to provide an adequate number of personnel appropriately assigned, there is a responsibility to provide personnel qualified to do the job. Basic qualifications are frequently determined by the personnel office as a result of reviewing a n application for employment. This is adequate to determine the basic education, previous employment (not experience), and to filter out the obvious undesirables. However, the custom of interviewing and hiring nursing personnel in the personnel department leaves much to be desired. The maximum assessment one is able to make, based on the standard personnel form, is: 1. Basic education: There is no information to describe exposure to a special area, the quality of instruction, or the suitability of the applicant. 2. Previous position: This is not synonymous with previous experience. There is considerable difference. It is impossible to assess the actual experience of the applicant by means of the usual written application form.
526
By compiling data, one can arrive a t years of employment, but is this significant data? What significance is there in the fact that a n individual has one year, two years, or ten years OR experience, unless there is specific data about the kind of experience? Can qualifications be adequately determined on paper or by a personnel officer? The OR supervisor is the best person to determine the ability of a n applicant to meet the needs of her department. By means of interview, she can gain multiple clues to experience as opposed to previous jobs, job knowledge as opposed to basic education, suitability as opposed to availability. The OR supervisor can put these clues together and create a profile of the applicant. It is a time-consuming task, but it is a responsibility. The reference form is another standard procedure of dubious value. Certainly, i t identifies the very bad and the very good, but what about those in between? How many supervisors under admonition from the personnel department to be careful and in fear of becoming involved in a legal action are willing t o tell the whole truth? Once the employee has left her department, relief and indifference may replace conscience, and the supervisor will fill out the confidential reference form right down the middle. How many of you are currently burdened with a staff member who is mediocre with borderline competency because someone was reluctant to be forthright? If you don’t have input to the hiring of your staff, you have abdicated this responsibility to the personnel department. Adequate supplies and equipment are needed to care for the patient properly. Again, there are no rigid guidelines or specific rules. The umbrella of adequate care is still hover-
AORN Journal, October 1975, V o l 2 2 , No 4
S
tandards are established to render better care, not avoid prosecution.
ing over us. Some years ago, the law in many states looked sympathetically on the private hospital and excused it from liability under the doctrine of charitable immunity. It was thought that the assets or property of such a n institution were held in trust for the community and could not be sacrificed to benefit an individual plaintiff. Government or public hospitals were even more sacred because the care, however inadequate, was still free. These laws no longer exist in most states. When an institution opens its doors to the public, it is in essence telling the public “you may come here and expect to receive adequate care given by qualified personnel.” Standards of care have been established to render better care, not to avoid prosecution. These standards have been established by organizations such as JCAH, the federal government, professional organizations, and individual states. Although selfimposed, these standards are being looked to as guidelines for legal standards. Significantly, the trend in hospital liability law is toward national standards of care. The “local community standard” is disappearing. No longer is it possible for a n institution to be excused from the obligation to provide comprehensive quality care because it is small or rural. The hospital is recognized as a community
health facility from which the public is entitled to receive standard care, regardless of size, location, or governing body. Part of standard care is the availability of essential equipment to support medical and nursing judgments. Obtaining and maintaining operating room equipment is a voluminous problem facing every OR supervisor. Some companies are fiercely independent, especially when they hold the key or franchise to supply and repair a particular item. Instrument and equipment budgets are adversely affected by escalating costs. Purchasing departments, vendors, and delivery services appear to unite against OR supervisors when something is needed in a hurry. However, the responsibility to provide quality care is still there. Do you notify the posting clerk when essential pieces of equipment are out for repair? Do you refuse to book five cases requiring electrocautery units when you know the department has only four in operation? Do you continue to request and justify requests for equipment necessary to give adequate care? Do you look for a n alternative when your request is refused, or are you just tired of talking to a brick wall, or, even more unfair, being harrassed by that surgeon with the fifth case requiring a n electrocautery? Stick to your guns. You are obli-
AORN Journal, October 1975, V o l 2 2 , No 4
521
gated to maintain a standard of safe quality care in your area of responsibi1ity . The fifth area of responsibility is the most difficult for most nurses to adjust to, especially nurses who emerged in the era of nurses being “doctor’s helpers.” This is the responsibility to report any unusual or obviously substandard care by a physician or another nurse. Peer evaluation is relatively new in the nursing profession. Monitoring care given by a physician is so new as to send the fear of reprisal through many nurses. The role of the nurse as the patient’s advocate emerged long after the role of the nurse as an inferior assistant to the physician. It may take a bit more time t o establish guidelines for behavior in this new role. Nurses know by their education and experience what constitutes usual precaution and standard care, and it behooves them to note any observation that indicates either is not being carried out. If there is a flagrant violation of good or standard patient care, it is both a moral and legal obligation to bring this to the attention of the nursing administration, chief of surgery, or medical director of a n institution. If you fail to do so, there may be repercussions far greater than the wrath of an irate physician. In the case of Darling vs Charleston Community Memorial Hospital, Illinois, 1965, a football player was admitted to the emergency room with a fractured leg. He was treated by the doctor on emergency room call, a general practitioner who placed the leg in a cast. Over a period of days of hospitalization, the patient complained of agonizing pain in the leg. His toes became swollen, dark, and eventually insensitive. The doctor visited daily and apparently was satisfied with the pa-
528
tient’s progress. The nursing staff noted the complaints, the change in appearance of the toes, and ultimately a foul odor arising from the cast. Subsequently, the young man’s leg was amputated as a result of impaired circulation and gangrene. What kind of blinders were the nurses wearing to prevent them from seeing their obligation to do something definitive t o help the patient? Any registered nurse should recognize the symptoms of impaired circulation. To assume otherwise is to question seriously if nurses are properly prepared to meet the simplest nursing responsibility. In this case, the nurses escaped prosecution. The patient brought charges against the hospital and the physician. Both were found liable. The patient had every right to bring charges against the nurses, but nurses were not yet being held legally accountable for their actions in many instances. Today, those nurses would probably be named in such a suit, and rightly so. I am not suggesting that a nurse is a monitor of medical care. Surgeons have their responsibilities and their ethics. But it is the responsibility of nurses to make their observations known and in that way to be accountable and to insure that all others concerned with patient care are accountable for the quality of care given. If you can honestly say you have been prudent in carrying out this responsibility, then you are exempt from the reach of both guilty conscience and the law. Responsibility is one regulating mechanism enabling us to live as social beings. The nature of one’s responsibility is dependent upon one’s role in society. Traditionally, mothers are responsible for infants, fathers for households, nurses for patients. In the operating room, nurses have accepted
AORN Journal, October 1975,V o l 2 2 , N o 4
the responsibility for caring for the acutely ill and highly dependent patient. It is not, however, the magnitude of the responsibility that determines the success of a person as a social being, but rather it is the manner in which that person fulfills his responsibility. Are nurses abdicating responsibility? Yes, some are, through ignorance of those responsibilities and others through apathy. However, the vast majority are simply struggling with the task of identifying their responsibility and educating themselves regarding 1egal obl iga ti on. If you are guilty of abdicating responsibility because you are apathetic, I hope I have made you uncomfortable. Professional nurses have come a long way since Florence Nightingale recruited her first "nurse" from the slums of London. Professional nurses cannot jeopardize the results of 120 years of upward struggle by condoning apathy, excusing ignorance, or ignoring indifference. 0
References Benedikter, Helen. "JCAH standards: Why the trauma?" AORN Journal, 14 (September 1971). Carroll, Walter. "Joint Commission myth-(and the reality.)."AORN Journal, 14 (September 1971). Gouge, Ruth. "OR nurses face potential liabilities." AORN Journal, 20 (October 1974). Regan, William. The Regan Report on Nursing Law. 14, No 12, Regan, 1973. Roberts, Bruce. "Accreditation and legality." AORN Journal, 14 (September 1971). Springer, Eric. Nursing and the Law. Health Law Center, Pittsburgh, 1970. US Department of Health, Education, and Welfare Social Security Administration. Conditions of participation: Hospitals, federal health insurance for the aged. Code of Federal Regulations, Title 20, Chapter 111, Part 405.
New PSROs funded in 49 areas More than $21 million have been awarded to physician organizations for the initiation, planning, or support of medical review of federally financed health care by the US Department of Health, Education, and Welfare (HEW). The Professional Standards Review Organization (PSRO) legislation enacted by Congress in 1972 authorizes qualified physician groups to carry out peer review to assure that hospital and other medical care paid for by the Medicare, Medicaid, and Maternal and Child Health programs is medically necessary, is provided in the most appropriate health care setting and meets local standards of medical quality. Forty-nine PSROs, having successfully completed a year of planning activities, will begin to perform review of care provided in hospitals in the areas covered by the PSROs. The PSRO law requires that such groups operate on a conditional basis for up to two years, following which the HEW secretary may designate them as being fully operational. The 49 new conditional PSROs join 14 other comparable organizations in 12 states that have been in operation during the past year. Membership in the PSRO is open to all practicing physicians of medicine and osteopathy in its area, and the 63 conditional PSROs have memberships that range from approximately 30 to 90 percent of the physicians in their areas. In addition, federal PSRO planning funds have been awarded to 16 new physician organizations in 1 1 states. These groups will begin a year of start-up activities to eventually qualify to begin PSRO review on a conditional basis. To provide technical and professional assistance to multiple PSROs in certain of the nation's larger states, HEW also funded statewide PSRO support centers in Massachusetts,Connecticut, New York, New Jersey, Pennsylvania, Maryland, Virginia, North Carolina, Missouri, Ohio, Indiana, Michigan, and California.
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