2.2 Ethical and Professional Foundations of Safe Medication Administration by Nurses

The American Nurses Association (ANA) is a professional organization that represents the interests of the nation’s four million registered nurses and is at the forefront of improving the quality of health care for all.^[1] The ANA establishes ethical and professional standards for nurses that also guide safe administration of medications. These code of ethics and professional standards are described in ANA publications titled Code of Ethics for Nurses and Nursing: Scope and Standards of Practice.

Code of Ethics for Nurses

The ANA developed the Code of Ethics for Nurses as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.^[2] Several provisions from the Code of Ethics impact how nurses should administer medication in an ethical manner. A summary of each provision from the Code of Ethics and how it pertains to medication administration is outlined below:

• Provision 1 focuses on respect for human dignity and the right for self-determination: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”
• Provision 2 states, “The nurse’s primary commitment is to the client…”^[3] In health care settings, nurses often experience several competing loyalties, such as to their employer, to the doctor(s), to their supervisor, or to others on the health care team. However, the client should always receive the primary commitment of the nurse. Additionally, the client has the right to accept, refuse, or terminate any treatment, including medications.
• Provision 3 states, “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient…”^[4] This provision includes a nurse’s responsibility to promote a culture of safety for clients. If errors occur, they must be reported, and nurses should ensure responsible disclosure of errors to clients. This also includes proper disclosure of questionable practices, such as drug diversion or impaired practice by any professional.
• Provision 4 involves authority, accountability, and responsibility by a nurse to follow legal requirements, such as state practice acts and professional standards of care.
• Provision 5 includes the responsibility of the nurse to promote health and safety.
• Provision 6 focuses on virtues that make a nurse a morally good person. For example, nurses are held accountable to use their clinical judgment to avoid causing harm to clients (maleficence) and to do good (beneficence). When administering medications, nurses should validate the medication is doing more “good” than “harm” (adverse or side effects).
• Provision 7 focuses on a nurse practicing within the professional standards set forth by their state nurse practice act, as well as standards established by professional nursing organizations.
• Provision 8 explains that a nurse must address the social determinants of health, such as poverty, education, safe medication, and health care disparities.^[5]

Whenever a nurse provides client care, the ANA’s Code of Ethics should be used as a guide for professional ethical behavior.

Standards and Scope of Practice

The ANA publishes Nursing: Scope and Standards of Practice. This resource establishes national standards for nurses and is updated regularly.^[6]

The ANA defines the scope of nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.” A registered nurse (RN) is defined as an individual who is educationally prepared and licensed by a state to practice as a registered nurse. Nursing practice is characterized by the following tenets^[7]:

• Caring and health are central to the practice of the registered nurse.
• Nursing practice is individualized to the unique needs of the health care consumer.
• Registered nurses use the nursing process to plan and provide individualized care for health care consumers.
• Nurses coordinate care by establishing partnerships to reach a shared goal of delivering safe, quality health care.

The ANA establishes Standards of Practice and Standards of Professional Performance in the Nursing: Scope and Standards of Practice publication. State nurse practice acts further define the scope of practice of RNs and Licensed Practical Nurses/Vocational Nurses (LPNs/VNs) within each state. Nurse practice acts are further discussed in the “Legal Foundations and National Guidelines for Safe Medication Administration” section of this chapter.

Standards of Practice

The ANA’s Standards of Practice are authoritative statements of duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Standards of Practice include assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ADOPIE) components of providing client care, also known as the “nursing process.” When nurses safely administer medication, all components of ADOPIE are addressed.

Assessment

The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”^[8] A registered nurse uses a systematic method to collect and analyze client data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, when a nurse assesses multiple pieces of data for a hospitalized client with pain, this is considered part of a comprehensive pain assessment.

Diagnosis

The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”^[9] A nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. Nursing diagnoses are used to create the nursing care plan and are different than medical diagnoses.^[10]

Outcomes Identification

The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”^[11] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the client based on their assessment data and nursing diagnoses.

Planning

The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”^[12] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each client’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the client’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care.^[13]

Implementation

The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.”^[14] Nursing interventions are implemented or delegated to licensed practical nurses/vocational nurses (LPNs/VNs) or unlicensed assistive personnel (UAP) with supervision. Interventions are also documented in the client’s electronic medical record as they are completed.^[15]

The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment.^[16]

Coordination of Care

The ANA standard for coordination of care states, “The registered nurse coordinates care delivery.”^[17] When ensuring medications are administered safely, the nurse collaborates with the client and the interprofessional health care team to meet mutually agreed upon outcomes. The nurse also engages the client in self-care to achieve their preferred goals for quality of life.  For example, one client with chronic pain may have a pain management goal of “5” with their quality of life preference of having the ability to participate in social activities with friends but not experiencing burdensome side effect of medication. Another client with chronic pain may have a pain management goal of “0” with a quality of life preference of having no pain no matter what the side effects. The nurse advocates for these clients’ goals and preferences with the interprofessional team.

Nurses also serve vital roles in ensuring safe transitions and continuity of care regarding clients’ use of medications. Additional information about safe medication use and transitions of care is discussed in the “Preventing Medication Errors” section of this chapter.

Health Teaching and Health Promotion

When administering medications, nurses teach clients about the medications and potential side effects to promote optimal health. The ANA standard for health teaching and health promotion states, “The registered nurse employs strategies to teach and promote health and wellness.”^[18] Specific behaviors related to teaching about medication are as follows^[19]:

• Use health teaching and health promotion methods in collaboration with the client’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
• Provide clients with information and education about intended effects and potential adverse effects of the plan of care.
• Provide anticipatory guidance to clients to promote health and prevent or reduce risk.

In the book Preventing Medication Errors by the Institute of Medicine (2007), the following are additional key national guidelines when teaching clients about safe use of their medications:

• Clients should maintain an active list of all prescription drugs, over-the-counter (OTC) drugs, and dietary supplements they are taking, the reasons for taking them, and any known drug allergies. Every provider involved in the medication-use process for a client should have access to this list.
• Clients should be provided information about side effects, contraindications, methods for handling adverse reactions, and sources for obtaining additional objective, high-quality information.^[20]

Evaluation

The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”^[21] During evaluation, nurses assess the client and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the client’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.^[22]

Standards of Professional Performance

ANA’s Standards of Professional Performance describe a competent level of behavior for nurses, including activities related to ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice, and quality of practice.^[23]

The ANA defines culturally congruent practice as the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the health care consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses must assess the cultural beliefs and practices of their clients and implement culturally congruent interventions when administering medications and teaching about them. Additional information about cultural implications for medication administration is further discussed in the “Cultural and Social Determinants Related to Medication Administration” section later in this chapter.

Figure 2.1 is an image from Nursing: Scope and Standards of Practice by the ANA that illustrates how the scope of practice, standards of practice, and code of ethics form the “base” of nursing practice.^[24] Nursing practice is further guided by the Nurse Practice Act in the state in which a nurse works, federal and state rules and regulations, institutional policies and procedures, and self-determination by the individual nurse. All these components are required to provide quality, safe client care that is evidence-based. These components will be further discussed in the remaining sections of this chapter.

NCLEX and the Clinical Judgment Model

The National Council Licensure Examination (NCLEX) is the national exam that graduates must pass successfully to obtain their nursing license after graduating from a nursing program of study. The NCLEX-PN is taken to become a licensed practical/vocational nurse (LPN/VN), and the NCLEX-RN is taken to become a licensed registered nurse (RN). The purpose of the NCLEX is to evaluate if a nursing graduate demonstrates the ability to provide safe, competent, entry-level nursing care. The NCLEX is developed by the National Council of State Boards of Nursing (NCSBN), an independent, nonprofit organization composed of the 50 state boards of nursing and other regulatory agencies.^[25]

A new edition of the NCLEX was launched in April 2023 that contains “Next Generation” questions. The Next Generation NCLEX (NGN) assesses how well the candidate can think critically and use clinical judgment. The NCSBN defines clinical judgment as “the observed outcome of critical thinking and decision-making. It is an iterative process with multiple steps that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions in order to deliver safe client care.”

The NCLEX uses the NCSBN’s Clinical Judgment Measurement Model (NCJMM) to assess the candidate’s ability to use safe clinical judgment when providing nursing care. Exam questions used to assess clinical judgment may be contained in a case study or as individual stand-alone items. A case study contains six questions that are associated with the same client scenario and addresses the following steps in clinical judgment^[26]:

• Recognize cues: Identify relevant and important information from different sources (e.g., medical history, vital signs).
• Analyze cues: Organize and connect the recognized cues to the client’s clinical presentation.
• Prioritize hypotheses: Evaluate and prioritize hypotheses (based on urgency, likelihood, risk, difficulty, time constraints, etc.).
• Generate solutions: Identify expected outcomes and use hypotheses to define a set of interventions for the expected outcomes.
• Take action: Implement the solution(s) that address the highest priority.
• Evaluate outcomes: Compare observed outcomes to expected outcomes.

Throughout this book, learning activities are provided to assist students in learning how to apply the nursing process (i.e., ANA’s Standards of Care) to answer NGN-style questions that evaluate clinical judgment. Some of these activities are written, with answers in the Answer Key at the end of the book, and others are interactive and require use of the online book.