by	Linda J. Shinn, MBA, RN, CAE Judith Cipriano Teri Britt, MS, RN JoAnn B. Reckling, PhD, RN Robin Welsh, JD, RN Barbara Sattler, DrPh, RN

To obtain the print publication that this CE is based upon, see Take Control: A Guide to Risk Management which can be purchased online.

Table of Contents

• Abstract and Objectives

• The Importance of Professional Liability Insurance in Managing Risk
  • Changes in Healthcare Financing
  • Changing Practice Settings
  • Litigious Nature of Americans
  • Pressure from the Plaintiff's Bar
  • Nurse Practice Acts
  • Transfer of Risk
  • To Purchase or Not to Purchase, That Is the Question
  • Purchasing Professional Liability Insurance
  • Occurrence or Claims-made Coverage
  • Your Obligations to the Insurance Companys
  • Know What's Covered
  • Summary

• Managed Care and Managing Risks
  • Managed Care
  • Roles for Nurses in Managed Care
  • Accountabilities for Health Care Providers
  • Legal Implications
  • Interview
  • Summary
  • References

• Ethics and Managing Risk
  • Organization-wide View
  • Medical Errors
  • Regulations, Standards, Policies, and Procedures Regulations
  • Selected Areas of Focus
  • Electronic Information
  • Environmental/Occupational Hazards
  • Restraints
  • Summary
  • References
  • Appendix I - ANA Code For Nurses
  • Appendix II - Code of Professional Responsibility

• Occupational and Environmental Risks in Nursing
  • An Overview
  • Latex Risk
  • Hospital Waste
  • Summary
  • References

• Attachment 1 Common Terms

• Attachment 2 How to Understand

• Attchement 3 ANA Reference Publications

• Attachment 4 SNA and State Licensing Boards

Abstract and Objectives

Abstract
In 1998, the independent study text "Take Control: A Guide to Risk Management" was published and co-provided by Seabury & Smith (formerly Maginnis & Associates), the Chicago Insurance Company and the Illinois Nurses Association. It was distributed by the American Nurses Association's Constituent Member Associations. The objectives of this text were to: identify key issues of concern in risk management and describe strategies nurses can use to manage risk.

Seabury and Smith Corporation has now asked ANA to transform this text into "The Nursing Risk Management Series" of three different independent study modules (ISMs) for placement on ANA's Nursingworld.org Web Site. The information and knowledge gained should assist nurses in all clinical practice areas to take control and manage the risks within their individual workplace and nursing practice.

Each module contains the abstract, specific objectives, text, reference list through 1998, an updated reference list through June 2001, the nursing post test and its feedback section. The registrant who successfully completes each ISM will earn ANA's nursing continuing education contact hour certificate. These independent study modules are: I: "An Overview of Risk Management" (1.4 contact hours); II: "The Rewards and Risks of the functional Aspects of Nursing Education, Information systems and Management" (2.8 contact hours) and III. "Ethical Issues and Specific Risk Hazards Faced by Nurses in Their Practice." (1.4 contact hours).

Objectives:

1. Describe the importance of professional liability insurance in managing risk.
2. Explore ways that managed care has changed roles and subsequently impacted risk for nurses.
3. Explain the ethics of managing risks from two perspectives: 1) an organization's wide view and 2) other selected areas of focus
4. Discuss an overview of environmental health & safety risks in the health care industry.
5. Analyze the occupational health risk of latex exposure and the environmental risk of hospital waste both of which affect nurses and the patients for whom they care.

The Importance of Professional Liability
Insurance in Managing Risk

All professionals incur the risk of being sued and of losing a substantial judgment. Often guilt or innocence has less to do with the outcome than does the public's perception of a plaintiff's needs. Risk is real. The issue is how one should efficiently manage risk, including its transfer to institutions skilled at managing it. And healthcare professionals' risk is increasing because of a number of factors.

Changes in Healthcare Financing

With the advent of managed care and the efforts of healthcare institutions to control healthcare delivery costs, patient care has undergone dramatic changes. Individuals admitted to healthcare institutions for in-patient care are generally more acutely ill than in the past, and they are discharged to alternative care sites quicker. Along with the changes in patient profiles, healthcare facilities' staffing has also changed, with nurses becoming more active as individual participants in the medical treatment process, while at the same time becoming increasingly responsible for unlicensed assistive personnel, nurses' aides, and other minimally trained workers.

Changing Practice Settings

Early discharge of patients, many of whom are still acutely ill, to alternative care sites, most frequently the patients' own homes, has also served to increase the responsibility of nurses in the care delivery process. Often, the nurse is not only responsible for the delivery of direct care but is also responsible for management of the care delivery team, including assessing the need for other services such as physical therapy, occupational therapy, and respiratory therapy, making these care recommendations, and monitoring the results. The nurse may also be responsible for the supervision of unlicensed personnel such as personal care attendants and nurses' aides.

With this increased responsibility comes an increased exposure to liability risk, and these changes have not gone unnoticed by plaintiffs' attorneys.

Litigious Nature of Americans

Advancements in technology and procedures have produced a conundrum: medical practitioners and their patients enjoy the benefits of early detection and diagnosis, the ability to treat illness in its early stages, and less invasive surgical procedures. Correspondingly, Americans' perceptions of what healthcare professionals can and cannot do has become increasingly unrealistic. Medicine is an art, not an exact science, and nature and other biological factors play a role in outcomes. Yet Americans believe that all outcomes should be perfect and are quick to place blame on medical professionals if optimal results are not achieved. They are also quick to seek redress within the legal system, and our courts seem to encourage this behavior. How often have you picked up your newspaper only to see banner headlines announcing a large award to a plaintiff because of injury allegedly caused by a medical professional? It sometimes appears that our courts do not make a distinction between a imaloccurrence' (a risk associated with a particular treatment) and malpractice, and the public's perception of 46someone must pay" is further encouraged.

Pressure from the Plaintiff's Bar

Plaintiff attorneys also play a role in this "lottery system." How often do you hear advertisements from attorneys on television, advising the public that they have a right to collect damages if injured by a medical practitioner, advising them that if their children are found to have learning disabilities upon starting school, they can sue the practitioner who delivered the child?

Nurse Practice Acts

Recognizing that increasingly nurses are returning to school to obtain advanced degrees, that they are specializing in specific fields of practice, and that they are assuming more of a leadership role in healthcare delivery, state laws regulating nursing practice have increasingly recognized instances in which nurses are held legally accountable for exercising judgment independent of the physician. This is a positive for the profession, but you must be aware that along with increased responsibility and recognition comes increased exposure to liability.

Transfer of Risk

How do healthcare professionals manage their exposures to liability? The most common means is to purchase professional liability insurance. Liability for one's own acts cannot be transferred. What can be transferred is financial responsibility for damage awards (indemnity) and the legal fees incurred in determining what those damages are (defense). Consider this: generally, the annual premium for professional liability insurance is modest. Whether there has been true liability or not, legal fees alone may cost tens of thousands of dollars to prove that there was no negligence or malpractice. In purchasing insurance then, a professional makes a decision that it is worth spending a little to potentially save a lot.

To Purchase or Not to Purchase, That Is the Question

Many nurses believe that if they purchase professional liability insurance, they will increase their chances of being named in a malpractice suit. Many employers encourage this notion, as it is easier and more economical for an employer to manage a liability claim if the interests of individual employees are not being individually protected. The fact is, however, that most. lawsuits are filed before a plaintiff's attorney has any knowledge of whether a defendant has insurance or not. It is only during the discovery phase that this information is learned. And, in today's world, the plaintiff's attorney will name everyone who is remotely connected to a patient's care in order to have the largest sum of money available as possible to satisfy a damage award. If you have signed the chart, you will probably be named, even if the care provided is tangential to the events which actually caused the injury.

Other nurses believe that their employer's professional liability insurance provides all of the coverage needed. While this is certainly true in the majority of cases, there may be instances in which the interests of an individual may be in conflict with that of the employer. In fact, if the event leading to a malpractice claim was contrary to the policies and protocols established by the employer and the employer is sued, the employer can file a claim against the practitioner to recover awarded damages and attorney fees.

A third reason for considering the purchase of personal professional liability protection is for acts performed outside of the scope of employment. As an example, if a nurse accepts a moonlighting position, a full-time employer's insurance plan will not cover any adverse events. Nurses are commonly called upon by friends, neighbors, and relatives to assess a medical situation and to provide care or to suggest a course of action. If erroneous advice or care is given, the nurse can be sued for the resulting injury. Again, the employer's policy would not respond as the event did not occur in the course of employment activities; the nurse would be personally liable for all resulting expenses. And what about Good Samaritan acts such as stopping to assist in an automobile accident or attending to a person who falls on the street? While most states have Good Samaritan statutes which prevent making a claim against an individual who assists another without being remunerated for care given in an emergency situation, individual events such as a claim for gross negligence could waive the protection afforded by such a statute. And, furthermore, these statutes, although providing some protection against loss, do not protect against being sued and incurring the cost of defense.

If, after understanding the limitations of employer supplied liability insurance, a nurse makes an informed decision to rely on this risk transfer vehicle, he/she should investigate the nature of the policy/plan affording the protection. It might also be advisable to request a copy of your employer's policy/plan and have it reviewed by an insurance professional.

Purchasing Professional Liability Insurance

If you choose to purchase your own individual professional liability insurance policy, there are several things you should consider in selecting the company to insure you.

The reason you have chosen to transfer your personal financial risk is to mitigate financial devastation should you cause or be accused of causing injury to another as a result of your professional service or judgment. Generally, the coverage provided by a professional liability policy is fairly standard: the insurance company agrees to defend you if you are named in a claim resulting from an adverse event, pay the legal fees associated with such defense, and pay damages up to the limits of coverage which you have selected if you are found negligent. But there are provisions in each insurance policy which gives each insurance company latitude in how its obligations to you are satisfied.

One of the most important things to consider is the policy's settlement provision. All nurses' professional liability insurance policies require that the insurer provide and pay for your defense and pay damages. However, the insurer has latitude in determining how these duties will be honored. Some companies retain the right, with no input from you, to settle a claim as it deems appropriate. In this instance, a decision for claims settlement may be based upon monetary considerations only (i.e., less costly for the company to settle than to defend), regardless of the effect on your career or your professional reputation. It therefore becomes important to seek out a professional liability insurer who will consult with you in the settlement process and who may not settle without your expressed written consent. This allows you to be a participant, not a bystander, in the claims adjudication process.

Consider the insurance company's experience in providing this coverage. Those companies with a long history of offering professional liability coverage to healthcare professionals are probably your best option. All companies, irrespective of the product or service, look to expand and diversify their offerings to consumers. This includes insurance companies as well. Neophytes in any business must learn as they go, modifying and streamlining, re-engineering as "bugs" are discovered before they become expert in something new.

An insurance company experienced in providing medical malpractice coverage generally works with a panel of attorneys with proven expertise in healthcare-related malpractice claims. These attorneys understand the investigative process, understand the operations of the healthcare delivery system, and work with a network of healthcare professionals to assist in the assessment of the medical facts. They potentially have handled claims with similar allegations and events and, from a historical perspective, can advise you of the wisest course of action.

The financial stability of the chosen insurance mechanism is of utmost importance. Medical professional liability claims have a long "tail" which means that it may be years, after an adverse event has occurred, until a claim is made. States have varying "Statutes of Limitations," the period of time following an adverse event in which the injured party can make a claim; however, there are various reasons a judge could choose to "toll" the statute (allow a claim to be made after the Statute of Limitations has expired). Concealment of the injury by the professional delivering care, foreign objects left in the body cavity which are not discovered until years later, and injury to minors are all reasons to toll the statute.. Thus, it is easy to see why financial stability is of critical importance; you want your insurer to be there for you in a claims situation, even if it occurs years after the event. Many Risk Retention Groups, a form of self-insurance, have become financially impaired and dissolved. Financial impairment is not limited to self-insurance plans or Risk Retention Groups. In the past decade, several insurance companies, generally small specialty companies formed to insure a specific group of professionals, have ceased operations because state regulators of insurance have found them to be insolvent. All insurance companies are rated by A.M. Best Co., which assigns a letter grade to signify the financial health of the company, with A++ being the best rating possible.

Occurrence or Claims-made Coverage

The most common form of coverage for staff nurses remains occurrence; however, some advanced practice specialties, most notably nurse-midwifery and anesthesiology, are generally insured on a claims-made form. Both forms of coverage are the same in that the insurance company has the duty and the obligation to defend claims and pay damages. The difference lies in which policy applies at the time the claim is made.

With occurrence coverage, the policy in effect at the time the adverse event occurred is the policy that responds. The advantage of this form of coverage is knowing that you will be afforded coverage even if a claim for damages is not made until years later. The disadvantage is that the coverage terms and conditions and the limits of coverage selected, maybe years earlier, are those that apply; therefore, protection may be inadequate. In the early 1970s, medical malpractice awards were small in comparison to those awarded today. Physicians and surgeons commonly carried limits of $25,000 for each claim, and nurses did not concern themselves with insuring their personal liability; claims against nurses were a rarity. Claims-made coverage did not exist. Let's say that an obstetrician was sued today for a "bad baby" boom in the early 70s. Because the obstetrician had an occurrence policy, the total coverage limit available would be $25,000, hardly sufficient to cover the monetary awards made today. The obstetrician would then be personally responsible for any award in excess of that $25,000.

With claims-made coverage, the adverse event must occur and the claim must be made during the policy period. The advantage to this form of coverage is that current terms and conditions and current limits of coverage would respond to the claim. The disadvantage of claims-made coverage is the need to purchase extended reporting period coverage once you cease practicing in order to be adequately protected for claims made in the future for events that occur today. Purchasing extended reporting period coverage allows a professional to continue coverage for events that occurred during the coverage period once the policy is canceled or non-renewed. It might be advisable for a professional to explore tail funding mechanisms, since the early years of claims-made coverage are generally less expensive than occurrence coverage, so that the purchase of extended reporting coverage will not present a financial burden.

Your Obligations to the Insurance Company

An insurance policy is basically a two-party contract. As in any contract, both parties have certain obligations. The insurance company is obligated to defend you in the event of a claim or suit and to pay damages within the selected coverage limits. You are obligated to be truthful in your application to the company for coverage, to pay your premium when due, and to comply with the Conditions of Coverage as stated in the policy. One of these conditions is to notify the company as soon as possible if you are involved in an adverse event.

Know What's Covered

It is important to understand the limitations of the coverage provided. All insurance policies contain specific exclusions from coverage, and they vary from insurer to insurer. You must read your policy to determine what is covered and what is excluded; however, all insurance policies exclude criminal acts. It is illegal for an insurance company to provide insurance for events which are against public policy.

Summary

Changes in healthcare delivery, a more litigious society, and increased responsibility and accountability for nursing practice yield greater exposure to liability risk. While nurses cannot transfer their accountability and responsibility for nursing practice to another, they can transfer financial risk for damages and legal fees through the purchase of professional liability insurance. When purchasing liability insurance, the nurse should determine what the policy covers and what he/she is responsible for under the terms of the policy. The nurse should also determine coverage provided, if any, by an employer's policy.

Judith Cipriano is Director of Product Development, Kirke -Van Orsdel, Inc., Maginnis and Associates Division, Chicago, Illinois.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Rotarius, T., Liberman, A. (September 2000). Professional liability insurance for health care organizations--several significant considerations. Health Care Manager, 19 (1), 59-64.

Showers, J.L. (February 2000). What you need to know about negligence lawsuits. Nursing 2000 30 (2), 45-9.

Managed Care and Managing Risks

Growth in managed care is changing the way care is financed, delivered, and evaluated. Managed care is a system that links financing and delivery of care and monitors usage, cost, and performance of health services. The vast and rapid changes in health care have many consequences for nurses. For example, nursing roles are changing to reflect the goals of managed care: triage, prevention, health promotion, care management, utilization management, and care coordination to name a few. Managed care organizations (MCOs) are employing nurses in new or expanded roles. The new responsibilities are accompanied by emerging areas of accountability. The purpose of this chapter is to explore ways that managed care has changed roles and subsequently impacted risk for nurses.

Managed Care

Managed care has expanded considerably in the last two decades. It has become the dominant form of health insurance in the United States. Early research comparing managed care to fee for-service care suggested reductions in overall health expenditures through a managed care approach (Prospective Payment Assessment Commission, 1997). There are indications that, at least in the private sector, managed care is contributing to decreased growth in health care spending. This has been accomplished, at least in part, by limiting both the price and use of services (Prospective Payment Assessment Commission, 1997). Because of the apparent success of limiting growth in spending at a time when this goal is crucial, the adoption of managed care strategies is likely to continue.

The move from fee-for-service care to capitated delivery systems requires a drastic change in thinking. These changes are summarized below (Sprenger, 1995):

Traditional
Capitation
Patient Model
Population-Based
Illness/Curative
Preventive/Wellness
Tracking Beds, Admits
Tracking Health Status/Outcomes
Service Use Generated Revenue
Service Use Increases Costs

Changing from fee-for-service to managed care involves many other transitions as well. The financial incentives of fee for-service involved reimbursement for each service provided; thus, the incentive was to provide more services. Instead of the insurer paying for services based on a fee-for-service, most managed care plans involve some form of capitation. This means that the providers are paid a set amount to provide care for a group of people over a defined period of time. Since capitated payment takes place prior to service delivery and covers a defined population over time, financial risk is shifted from the insurer to the provider. Capitation reverses the incentive because of the need to care for many people with a fixed amount of money. While over-service was the potential danger in fee-for service care, under-service poses a similar potential danger under capitation.

Well-established, traditional managed care organizations have several common attributes which can be maximized to provide high quality, evidence-based care. These have been identified as (Wagner, 1996):

• A clearly defined population
• Enrollees that are linked with a primary care provider
• Integrated services, providers, and facilities
• Integrated financial and clinical data systems
• A balance of professional power between primary and specialty care providers
• A unifying mission, culture, and organizational identity among providers
• Centralized resources such as patient education and home care
• A preventive orientation

These attributes make it possible to manage the care of patient populations. For instance, they provide the opportunity to identify patients with specific health problems, track health status, and monitor service use. If used effectively, these attributes can support collaborative efforts to optimize outcomes and manage costs by assuring delivery of effective services, without redundancy or gaps in care. In order to make the individual components work together, however, organizational structures and leadership must support population-based management with resources and staff that are capable of systematic care delivery (Wagner, 1996).

Of course, in addition to the potential promise of managed care, there are many areas of caution. The focus on self-management of health and preventive strategies is refreshing, yet it must be balanced with assurances of quality and access. Trade-offs between cost, quality, and access are at the center of this debate (Porter O'Grady, 1995).

The financial incentive in managed care is on not providing services and keeping as much of the capitation payment for reinvestment as possible. Short-term financial incentives provide significant areas of concern for policy makers, health care providers, and patients who yearn for long-term, high-quality solutions beyond the "bottom line." This poses serious questions related to access and quality. Nurses must be keenly aware of the underlying strategies and mechanisms in managed care in order to guard against poor patient care (Porter O'Grady, 1995).

Changes in the funding structure have had repercussions for the relationships between insurers, providers, and patients. Hospitals, in particular, have experienced financial pressures that have resulted from greater competition and insurer's demands for lower prices. Many hospitals, home health agencies, and managed care organizations have responded by changing the services they offer and contracting with other provider agencies (Prospective Payment Assessment Commission, 1997). These changes have contributed to a broadening array of roles for nurses.

Roles for Nurses in Managed Care

This section will explore emerging roles for nurses in managed care environments. These roles add challenges and opportunities for nurses. However, new opportunities bring new responsibilities that nurses must be aware of in order to manage risk effectively.

The American Nurses' Association has outlined a managed care curriculum for baccalaureate nursing programs, which highlights many roles for nurses in managed care environments (ANA, 1995). Major responsibilities and skills include provision of health promotion, prevention, health screening, and educational programs and services. In addition, nurses are called upon to engage in triage, referral, and case management activities. Nurses help patients learn and adopt self-care strategies and personal health management capabilities. Leadership roles include direction and support of ancillary personnel, staff performance evaluation, use of information systems, and effective communication (ANA, 1995). Advanced practice nurses such as nurse practitioners and nurse midwives are in high demand with MCOs. The added accountabilites in these new roles revolve around clinical competence not only for individuals, but also for population-based care management.

The transition from concentrating on an individual patient to focusing on patient aggregates or specific populations requires nurses to think in broader terms. Population-based care should expand upon a firm foundation of knowledge, competence, and skills focused on individualized patient care. The discipline of nursing has this strong knowledge base coupled with a fine tradition of community-based care. In many ways, the emergence of managed care represents opportunities for nursing to influence the future of health care delivery and financing. However, nurses must be poised to face this challenge by acquiring and using accurate information, responsible strategies, and a strong clinical foundation (Britt, Schraeder & Shelton, in press).

Population-based care involves skills that require an expanded nursing role. Graff, Bensissen-Walls, Cody, & Williamson (1995) describe the major elements of care provided by nurses in their expanded roles. Those that are applicable to population-based care include:

• Analysis of health services and systems in terms of accessibility, sensitivity to patient needs, and cost-effectiveness for the target population
• Design, direction, implementation, and evaluation of programmatic, technological, and educational directions for specified populations
• Care coordination across the health-illness continuum and across settings and beyond geographic boundaries
• Consideration of organizational, community, and cultural implications of events and decisions related to care coordination
• An emphasis on networks of providers, colleagues, and resources
• Enhanced relationships with patients and providers as a result of clearly defining and demonstrating the contribution of nursing to the consumer's health
• An emphasis on interdependent learning, open dialogue, collaboration, and a collective sense of responsibility
• Support of organization-wide, ongoing processes to improve service, clinical outcomes, and satisfaction

Nurses in population-based care must establish a system of care coordination for a specified sub-population of patients that spans the health care continuum and bridges the spectrum of health-illness. Nurses collaborate with physician colleagues to improve care for specified sub-populations (Graff et al, 1995). Roles and responsibilities for the expanded role of nurses in Graff's study included:

• Identification of an at-risk population
• Development of interventions to reduce risk factors
• Establishment of care coordination system
• Resource networks and critical linkages for patients and staff to assure access to needed services
• Data collection, monitoring, and analysis
• Identification of strategies to reduce hospital length of stay
• A focus on outcomes and a review of variances from standards of care
• Use of data to improve care and outcomes across the population

Population-based care creates an environment where nurses can use established skills and gain new ones. For instance, nurses can facilitate linkages between providers, managed care organizations, and patients by understanding and articulating the financial and clinical interests each party brings to the health system. Nurses can help define and quantify risk by participating in the assessment of patient and population health needs. When managed care organizations examine the community to determine and reduce high-risk health practices, nurses can play central roles. Nurses are well-equipped to define, measure, and manage outcome- related data to improve care strategies. However, the responsibilities of population-based care require that nurses be cognizant of the risks involved in potentially denying necessary services, violating confidentiality, and working with dueling financial and clinical incentives.

Managed care systems may give nurses strong forums for patient education, advocacy, and preventive efforts across care settings. In addition, nurses can provide unique insights into multiple aspects of quality issues (Britt, Schraeder, and Shelton, 1998). Nurses can play a vital role in the development of care strategies and clinical decision-making tools. For instance, the ethical questions arising from managed care stand to benefit from an informed and active voice representing the nursing perspective. In addition to promoting nursing opportunities, managed care highlights the need for nurses to be aware of risk management associated with innovative roles.

Some of the roles in managed care involve a different type of relationship between the health care provider and the patient. The role may be more detached, and the personal relationship with the patient may be absent (Emanuel, Ezekie & Bubler, 1995). This issue has concerned risk managers because of the potential for claim exposure. It has been suggested that as depersonalization of care increases, there may be an increase in the number of claims initiated (Fiesta, 1997). Furthermore, when the patient's expectations for care do not match the provider's expectations, it creates a strong potential for conflict (Guanowsky, 1995).

The new roles emerging in managed care emphasize the need for nurses to maintain a thirst for learning, ongoing persistence, keen awareness, and a willingness to be flexible (Spitzer, 1997). Innovative roles imply emerging areas of responsibility, including legal, ethical, and clinical accountability. The legal system is beginning to address these areas as managed care becomes more prominent.

Accountabilities for Health Care Providers

The expanded opportunities that managed care offers to nurses are accompanied by new accountabilites. As financial risk is shared by providers, including nurses, new areas of risk and risk management are also emerging. For instance, triage and utilization- management nurses now have obligations to ensure that the appropriate care is given. Difficulties may arise when nurses are trying to manage resources frugally and with allegiance to their employers, yet also trying to act in the patient's best interest. These issues have emerged in medical literature concerning physicians and their clinical decision-making. The nursing literature has also begun to reflect these issues as they impact nursing practice (Fiesta, 1997).

Some aspects of nursing accountability rest on traditional guidelines and standards, but their interpretations within a managed care environment are not yet well-established. Three areas of conduct that remain the focus of ethical and legal consideration are competence (measured by nursing standards), ethical practice (evaluated using the Code for Nurses), and illegal practice (as departures from the law) (ANA, 1994). While these three areas have long been used to determine the scope of ethical and legal practice, their interpretations and implications within a managed care context are new and still evolving. Nurses must be vigilant about staying up to date on the Nurse Practice Act in their state, nursing standards specific for their area of expertise, and current state and federal health laws. As managed care becomes the "workplace" for more nurses, it is likely that these ethical and legal tools will be used to guide the profession.

Legal Implications

Several factors have complicated the process of extracting risk management guidelines for nurses in managed care. These include the relative "newness" of managed care, the limited volume of litigation leading to a foundation of legal precedence, and the complex contractual agreements among the parties involved (Faulkner & Gray, 1996).

A number of suits involving managed care organizations are starting to wind their way through the appellate courts. As a result, liability issues are becoming clearer. For instance, failure to process claims appropriately, denial of claims (also referred to as a negligent utilization decision), and undue delay of treatment can lead to liability (Fiesta, 1997). Most of these issues have a common theme: "Who should be held liable when things go wrong?"(Faulkner & Gray, 1996).

The courts have addressed several cases related to poor patient outcomes alleged to have resulted from care received from or through managed care organizations. Traditionally, these claims would have been treated as malpractice claims. However, due to the intricate contractual arrangements between the many stakeholders (MCO, provider, patient, contracted service providers, etc.), it is quite challenging to delineate the legal responsibilities (Faulkner & Gray, 1996).

Following the legal process from the time a suit is filed to the establishment of legal precedent is lengthy and complicated. Legal precedent, and therefore guidance, is linked to the long time delay between a lawsuit being filed, counter-claims filed, cross-claims, preliminary motions, and the appeals process. Only after a trial verdict is appealed on legal grounds to a higher court and the court formulates an opinion can a precedent be established. As a result, risk management guidelines are difficult to institute because of incomplete information (Faulkner & Gray, 1996).

A stakeholder analysis, defining the various positions of the involved parties, is useful in delineating some of the perspectives involved (Faulkner & Gray, 1996): Managed Care Organizations. MCOs argue that they arrange for but do not actually provide care; therefore, if something goes wrong, traditional malpractice law should apply. The health care provider should be liable. Health Care Providers: The physicians counter the MCO argument by stating that they must follow the MCO contractual rules as expressed in peer review, utilization review, and clinical protocols. They maintain that the MCO should be held liable for the rules it imposes. Physicians have been the predominant clinicians involved in the managed care legal debates, but as nurses become more visible in managed care activities, they are likely to experience similar perspectives. Utilization Review Companies Behavioral Health Managers: These players determine the appropriate setting for care as well as whether and how long the care will be compensated by the MCO. However, when something goes wrong, they claim that they do not make clinical decisions: they determine compensation. Nurses working for these companies or in similar roles may be involved in this aspect of the debate as well.

These various perspectives have challenged the legal system. Traditionally, law relies on precedent when faced with new forms of behavior. When there is an absence of precedent, the system is forced to draw from other bodies of law to reach conclusions. This situation has led to some very interesting dynamics concerning managed care law (Faulkner & Gray, 1996). While a comprehensive treatment of these issues is well beyond the scope of this chapter, a few compelling examples will be outlined. An interview with nurse attorney, Jane Nelson Bolin, will then be presented.

• MCOs often adopt clinical practice guidelines to manage particular problems and improve care outcomes. In a relatively new phenomenon, guidelines may be admitted as inculpatory or exculpatory evidence by judges in malpractice claims (Brennan, 1997).

• Credentialing refers to the process of including the appropriate delineation of clinical privileges. In addition to physicians, MCOs may decide to credential "limited-license practitioners" (nurse practitioners, nurse midwives, physician assistants, physical therapists, etc.). MCOs may prefer to credential limited license practitioners because of their cost-saving potential and consumer demand, but physicians may protest because of the way the supervision of limited license providers impacts physician liability. Conversely, antitrust actions have been filed against MCOs by limited-liability providers who were excluded from credentialing (Mattioli, 1997).

• Any willing provider laws. These proposed laws were set up to require MCOs to pay any provider who agreed to meet the MCO's terms and conditions of participation for services provided to the enrollees, whether or not the provider is part of the MCO's network. They were launched by the concern that MCOs were restricting enrollee choice of provider. In 1996, 69 AWP proposals were introduced in 24 states but none passed. AWP proposals have now given way to new initiatives by MCOs to increase choice of providers including point of service (POS) options and self-referral systems (Roth, 1997).

"Gag" rules. "Gag" rules are a group of MCO contract provisions that restrict what a physician can discuss with a patient, primarily regarding treatment options, particularly those the plan does not cover. Many states have passed laws prohibiting gag rules, and the federal government (through the Health Care Financing Administration, HCFA) notified HMOs that Medicare and Medicaid beneficiaries were to be advised about all medically necessary treatment options (Roth, 1997).

• Disclosure of physician incentives. This is a provision of a proposal by the American Medical Association (AMA) that would require MCOs to disclose all "financial arrangements, incentives, or contractual provisions with hospitals, review companies, physicians, or any other provider of health services that could limit or induce the limitation of the services offered (or) restrict referral or treatment options (Roth, 1997)."

Interview with Jane Nelson Bolin R.n. Bsn J.d.

Many hospitals carry the BNA Health Law Reporter which provides monthly updates on reported decisions from around the country in all aspects of health law. I also recommend Alice Gosfield's book entitled, Guide to Key Legal Issues in Managed Care Quality, published by Faulkner & Gray, New York, NY (1996).

Finally, some Web sites of interest are: www.NHLA-AAHA.am (National Health Lawyers Assoc. Web site) www.medsite.com (Reports general medical news including cases of interest) wwwjjX.com42racficeAea1(h4ndex (National Law Journal Web site for health law articles and reported decisions) www.medchat.com (General medical news, including some decisions)

3. "Traditionally, if nurses worked in hospitals, they felt somewhat protected by the institution's liability policy. Do MCOs offer the same protection for nursing employees?"

ANSWER: I have not seen a case where an MCO denied liability for the acts of one of its employees, including nurses, but that does not mean it will not happen. The mere fact of an employment relationship does not guarantee that a nurse will not be named individually in a negligence lawsuit. Physicians are worried that the more complex nature of the MCO health care delivery environment will lead to added areas of exposure (Gosfield, Today's Internist,July/August 1997).

Because of the evolving nature of roles, nurses should not assume their actions are protected under the MCO's liability insurance policy. Depending upon the nature of the conduct, the MCO might make a decision not to defend a nurse in a malpractice lawsuit. The bottom line is that this is an area that is largely undefined in managed care case law. Read the MCO's policies and procedures and seriously consider purchasing your own policy of professional liability insurance.

Summary

Managed care has brought about many changes for the health care industry. Among these are transitions in nursing practice that are accompanied by new responsibilities. The legal system is developing a body of knowledge to guide the liability features of managed care, but its growth is incremental. Risk management strategies must rely on this developing body of legal knowledge. Emerging legal and clinical developments are adding twists and nuances to the way in which laws are interpreted. In order to manage risk in the new era, nurses must stay apprised of changes in managed care health law as well as being mindful of traditional malpractice concerns.

References

American Nurses Association (1994). Guidelines on reporting incompetent, unethical, or illegal practices. Washington, DC: ANA.

American Nurses Association (1995). Managed care curriculum for baccalaureate nursing programs. Washington, DC: ANA.

Brennan, T. (1997). Practice guidelines and malpractice litigation: Collision or cohesion? Presented at AHCPR Conference: Translating Evidence into Practice. Washington, DC.

Britt, T., Schraeder, C., & Shelton, P. (in press) Managed care and capitation issues. Monograph prepared for the American Nurses Association, Washington, DC.

Emanuel, E., Ezekie, & Bubler (1995). Preserving the physicianpatient relationship in the era of managed care. Journal of the American Medical Association. 273 (4), 338-339.

Faulkner & Gray (1996). Guide to key legal issues in managed care quality. New York: Faulkner & Gray's Healthcare Information Center.

Fiesta, J. (1997). Managed care liability update. Nursing Management. 28, 20-22.

Gosfield, A. (1997). Guide to key legal issues in managed care quality. New York: Faulkner & Gray's Healthcare Information Center.

Graff, W., Bensussen-Walls, W., Cody, E., & Williamson, J.(1995). Population management in an HMO: New rules for nursing. Public Health Nursing 12, 213-221.

Grimaldi, P. (1995). Capitation savvy a must. Nursing Management, 26,33-34.

Guanowsky, G. (1995) Liability in managed care for the health care provider. Nursing Management, 26,24.

Luft, H. (1981). Health maintenance organizations: Dimensions of Performance. New York: John Wiley.

Matliotti, M. (1997). Credentialing of limited license practitioners in a managed care environment: Antitrust liabilities and risk avoidance strategies. In A. Gosfield (Ed.) Health Law Handbook (pp.131-62). New York: Clark Boardman Callaghan.

Nelson Bolin, J., R.N. BSN J.D. (personal communication, February 26, 1998).

Porter-O'Grady, T. (1995). Introduction. Power, politics & public policy: A matter of caring. New York: National League for Nursing Press.

Prospective Payment Assessment Commission (1997). Medicare and the American health care system: Report to Congress. Washington, DC: Prospective Payment Assessment Commission.

Shamansky, S. L. (1996). Population-based managed care to improve outcomes. Nursing Economics, 14, 245-247.

Spitzer-Lehmann, R. (1996). "A new framework for managed care: Marrying finance and service delivery" presented at Managed Care: How to Negotiate and Administer Capitated Contracts, Nursing Management Congress, September 28, Chicago, IL.

Sprenger, G. (1995). "Healthier communities: A paradox in a capitated environment." Presented at The Healthcare Quest: Creativity in Capitation, July 15-16, Minneapolis, MN.

Roth, (1997). Anti-managed care laws: Patient protection or provider self-interest. In A. Gosfield (Ed.) Health Law Handbook (pp. 163-18 1). New York: Clark Boardman Callaghan.

Wagner, E., Austin, B., & Von Korff, M. (1996). Improving outcomes in chronic illness. Managed Care Quarterly, 4, 12-25.

Wagner, E. (1996). The promise and perfon-nance of HMOs in improving outcomes in older adults. Journal of the American Geriatrics Society, 11, 1251-1257.

Teri Britt, MS, RN is a doctoral student in the Health Policy and Administration program at the Pennsylvania State University. She also works as a Research Analyst with Carle Clinic Association's Health Services Research Center, Urbana, Illinois.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Gingerich, B.S. (August 1999). Corporate compliance. Compliance concerns: risk management and management of employee risk. Home Health Care Management & Practice, 11 (5), 65-66.

Lentz, J. (August 1999). Employment screening: risk management tools and essential compliance utility. Home Health Care Management & Practice 11 (5), 16-20.

Mahlmeister, L. , Van Mullem, C. (March 2000). The process of triage in perinatal settings: clinical and legal issues. Journal of Perinatal and Neonatal Nursing, 13 (4), 14-30.

Morris, M.R. (September 1999). Legally speaking. Preventing med errors. RN, 62 (9), 69-70, 72-3, 86.

Stahl, D. (October 1999). Tips for negotiating managed care contracts…surviving risk-sharing contracts. Curtin Calls, 1 (11), 8-9.

Sullivan, G.H. (March 2001). Legally speaking. Reduce your risk in the managed care jungle, RN 64 (3), 71-72, 74.

Ethics and Managing Risk

Awareness of the ethical basis and standards for managing risk in a healthcare environment is critical for practicing nurses. A fundamental assumption in the practice of nursing is the profession's ethical obligation to society and to the individual patient/client to provide high-quality nursing care (see American Nurses Association Code for Nurses, 1985, Appendix 1). Taking control of risk in practice promotes the delivery of high quality nursing care, which in turn assists in fulfilling the nurse's professional ethical obligation to society.

In this chapter the authors will discuss the ethics of managing risk from two perspectives: 1) an organization-wide view, and 2) other selected areas of focus.

Organization-wide View

Risk management is broad in scope. According to Guido (1997, pp. 290-291), "risk management is a process that identifies, analyzes, and treats potential hazards" in a circumscribed practice setting. The objective of risk management is to identify and eliminate potential hazards before anyone is harmed or disabled, and to develop and evaluate policies and procedures that provide guidelines for the institution and direct practice. These activities are, of course, helpful in protecting an institution from legal liability and potential financial disaster but more importantly, they serve to protect the public as well as healthcare personnel (See American Society for Healthcare Risk Management Code of Professional Responsibility, Appendix II).

The relationship of risk management to financial and legal liability is significant. Historically, the focus of risk management has been on financial liability awareness. According to Monagle (1985, p. 11), "the main function of the director of risk management is to ensure the financial solvency of the organization against ... risks at the least possible cost." Sullivan and Decker (1988, pp. 499-500) explained that "risk management follows the current trend of adapting business strategies to hospital management; it is the hospital parallel to product liability prevention in industry. They further described risk management as a planned program of loss prevention and liability control, but emphasized the importance of detection, education, and intervention.

It is the "self-protective" business focus of risk management that may provoke questions as to whether or not risk management is ethical. However, the issue is far broader than "simple" protection of institutions. The maintenance of viable, accountable healthcare service institutions is crucial to the health of the populace - a "greater good," in ethics terms, than not having such resources available.

The moral integrity of the risk management process and the individuals involved are critical. Integrity is broadly defined as a state of being whole. Moral integrity encompasses a coherence and consistency within a set of ethical principles and commitments so that these principles and commitments are upheld for the right reasons, even when challenged (McFall, 1987; Rushton, 1995). Ethical principles and virtues that ought to be part of a risk management process include respect for autonomy (self-determination), non-maleficence (do no harm), beneficence (act in the best interest of), justice (fairness), veracity (truthfulness, honesty), confidentiality, and fidelity (promise keeping, loyalty). Using ethical principles and virtues to maintain individual and institutional integrity will promote patient/ client well-being and will therefore be consistent and compatible with the legal needs of the healthcare facility (Haferneister & Hannaford, 1996).

The principle of veracity requires particular discussion in relation to risk management because of its association with the "duty to disclose." It is important here to emphasize that this discussion pertains to the ethics of veracity and disclosure and that legal advice ought to be sought for individual situations. Questions of meaning and scope of disclosure often arise in the practice of nursing and are more complicated when one is involved in a potential claim/suit. Beauchamp and Childress (1994) provide an in-depth discussion of veracity and the duty to disclose. In brief, veracity, or truthfulness, is based on the principle of respect for others, and it is clear that adherence to the rules of veracity is essential in fostering trust. Lying and inadequate disclosure clearly violate respect for others and impede a trusting relationship. However, veracity, like informed consent, is a concept that is not absolute because of its inherent nature: it deals with information, and the meaning and scope of information can be difficult to determine. Valid questions are frequently asked about the appropriate quantity and quality of information to be disclosed to individuals or the public-at-large in any given situation. While the intention is not to be deceptive, but rather to avoid alarming others, any withholding of information may be perceived as violating a duty to disclose. Legal advice is recommended when such questions arise, especially when risks are recognized.

Medical Errors

Medical errors are a common source of recognized risks, and concern about them is evident in current literature. According to Leape (1997), most medical errors (95%) go unreported. It is widely believed that the situation of underreporting (or failure to disclose) is because of the professional's fear of punishment, be it in the form of legal sanctions (civil or criminal), the loss of one's job, or disapproval of colleagues. Leape suggested that the healthcare industry's relaxed approach to error reduction (as compared with aviation and the space industry) is a result of an ineffective and counterproductive "train and blame" approach: the belief that mistakes can be avoided if everyone is trained not to make them and punished when they do (1994,1997). According to Leape, research has shown that while "errors are almost always made by individuals, error results from defects in the systems in which we work" (1997, p. 1). Unfortunately, as a result of underreporting, institutions have no reliable indicator of the severity of error problems. Thus, underreporting hinders the process of system improvement for system failures and is an issue of importance for nurses as they take control of risk in their practice.

For example, a nurse in an emergency situation gives the patient ten times the ordered dose of lidocaine IV push (bolus) to treat an arrhythrnia. The patient's heart stops; resuscitation procedures are necessary; and the patient incurs charges for the treatment and an increased length of stay in the hospital. If this had not been reported, the facility would have lost the opportunity to discover that the lidocaine for IV bolus administration and the lidocaine for dilution in an IV drip were stored next to each other in a drawer both in similar syringe-type containers. The individual nurse made the error, but the storage "system" made the effort more likely to occur.

Issues of veracity and disclosure in the case include many unanswered questions. Should the patient and/or family be told about the error? Who should tell them? How much information should they be given? It is generally agreed that when errors require treatment modifications to reverse or prevent adverse outcomes, the patient must be told. Patients have a right to be involved in treatment decisions (autonomy) and to know that they will not incur charges associated with treatment caused by error (justice). Usually the professional who can discuss treatment options with the patient should be involved in disclosing the error. Risk management staff or legal counsel should be consulted for assistance with the disclosure.

A more difficult situation arises when no harm comes from the error. Friedson (1997) addressed whether patients should always be informed, or if there are situations where nondisclosure may be therapeutically beneficial and, therefore, morally justified. One must consider whose needs are being served by non-disclosure-the needs of the professional or the patient ? Making a decision between worrying families needlessly and enriching caregiver and patient relationships by using full disclosure requires professional judgment. The literature includes reports that patients tend to respect and forgive healthcare professionals who are honest with them about mistakes (Christensen, Levinson, & Dunn, 1992; Finkelstein, Wu, Holtzman, & Smith, 1997) as well as reports that some might be more likely to take punitive action if they find out about an error that has not been previously disclosed (Witman, Park, & Hardin, 1996). Thus, when one chooses to limit or avoid disclosure, one must make that decision based on the benefit or harm to the individual, as well as on the issue of maintaining societal trust which is important in minimizing liability.

Clearly, the issue is far from settled. While it may be that the only way to ensure accurate reporting of errors is to provide protection from disclosure such as through peer-review activities, instead of by embracing the "train and blame" paradigm, this approach invokes questions about full-disclosure. Thus, we have a conflict where physic ian/nurse-patient integrity and the ethics of improving organizational integrity may stand in opposition to one another (Ross, 1997). But in the interest of improving organizational integrity and subsequently patient care, risk management must strive to address an error as a system failure versus a personal failure and support efforts to track, establish trends, and reduce error.

Regulations, Standards, Policies, and Procedures Regulations

Standards, policies, and procedures that influence the individual practice of nursing, as well as institutions, are often designed to uphold ethics-based precepts. Nurses whose relationships with patients/clients are in a direct care, one-on-one setting, as well as those who have professional managerial responsibilities (e.g., nursing management, quality assurance, or risk management positions) must ensure that mandates and guidelines are maintained. Several of the planks in the American Nurses Association Code for Nurses (1985) (Appendix 1) support nurses' responsibilities for understanding and interpreting regulations that have an impact on their practice (and therefore the health and safety of the public). However, it is essential that nurses distinguish between regulations and standards that are legally binding and policies and procedures that are recognized as being guidelines that allow for professional interpretation in individual situations.

As managed care expands and the potential for computer-based statistical tracking is realized, standards of practice are rapidly evolving. Some are based on sound research, while others evolve from less credible sources, but they are increasingly used as benchmarks to measure provider failure (Furrow, 1993). To control their own risk, nurses must remain alert and aware of the legitimacy of practice guidelines and standards that are being thrust upon them. Professional judgment is essential to protect the best interests of individual patients as well as the general public.

One source of widening and increasingly explicit formal expectations for ethical conduct within a healthcare service environment is the Joint Cornmission on Accreditation of Healthcare Organizations (JCAHO). JCAHO has recently incorporated standards for ethical considerations associated with managerial and business aspects of organizations, in addition to existing specific standards related to ethical issues in direct patient care (Spencer, 1997). Nurses across the country are currently involved in interpreting how these new regulations influence their practice, especially in light of the burgeoning number of managed care organizations.

Institutions are beginning to hire compliance officers to ensure that regulations and standards are being followed. Compliance officers are well known to the defense industry and evolved amid stories of the federal government paying hundreds of dollars for a hammer. They became a necessity for the healthcare industry when the Department of Justice announced that stopping fraud and abuse would be one of its main goals. The federal government committed billions of dollars to the effort. Compliance officers, however, will not only be occupied with Medicare billing requirements. They will undoubtedly be responsible for assuring compliance with the myriad of regulations and standards affecting health care.

Compliance officers will not be able to work in a vacuum. Compliance committees with institution-wide representation will often be one method used to ensure that the compliance plan is followed. Staff will need to be educated regarding the plan and encouraged to report suspected violations. Institutions would be better served having no plan than a plan that is not followed. Lockheed Martin Corporation adopted a code of ethics that included the following questions that may provide guidance for nurses: "When in doubt, ask yourself? What would I tell my child to do? How will it look in the newspaper? Will I sleep soundly tonight?" (Maintaining ethical conduct.... 1997).

For nurses seeking ethics-related information, the ANA provides more than 50 position statements, in addition to the ANA Code for Nurses (1985). The ANA position statements are available on the ANA Web site (American Nurses Association, http://www.nursingworld.org/readroom/position/index.htm). Specialty organizations are also potential information sources, as are institutional ethics committees.

Selected Areas of Focus

Managed Care With the increase in managed care organizations, nurses are finding themselves exposed to goals and regulations that appear to be business-focused rather than patient-focused. Concern has been expressed that the quality of nursing care is being jeopardized to save costs. The ethical principle of justice and how we can best allocate our scarce resources is the underlying ethical issue of concern as managed care grows. There are opportunities as well as challenges and concerns as we as a society restructure the healthcare delivery system, ideally in a manner that will promote a "greater good."

Within the issue of allocating resources, nurses encounter several other ethical issues as well. Quality of nursing care is related to the ethical principles of beneficence and nonmaleficence: acting in the best interest of the patient/client and doing no harm. Reduction in professional nurse staffing, substituting unlicensed assistive personnel (UAP) for professional nurses, and requiring nurses to provide patient care in specialty areas with which they are not familiar are some of the concerns expressed by nurses across the country. Balancing the benefits and burdens of such demands can be difficult for individual nurses and institutions alike; good communication, effective reasoning skills, and professional judgment are needed to reach solutions that uphold the ethical responsibilities of all involved. Various professional organizations provide information and guidelines for dealing with issues of quality of care. Informational topics addressed by the ANA include use of unlicensed assistive personnel, maintenance of professional and legal standards during a shortage of nursing personnel, quality indicators and the ANA's Safety and Quality Initiative, as well as background and suggestions related to practicing nursing in the era of managed care (See ANA Web site).

Issues of veracity have arisen related to managed care organizations limiting of information (e.g., treatment choices) that healthcare professionals can disclose to patients. Additionally, a conflict of interest can occur if healthcare professionals have a financial stake in the profit a company might make (limiting treatment options might save money and increase company profit). Legislation and policies are being developed and implemented to prevent "gag" orders and protect against conflict of interest, and managed care organizations and consortiums are developing their own codes of ethics.

An understanding of professional integrity and moral compromise is of value when a nurse encounters ethical dilemmas related to managed care or other practice issues and wishes to take control of his or her own risk. Winslow and Winslow (1991) suggested that compromise is compatible with moral integrity if a number of conditions are met and that nurses are in a position uniquely suited to leadership in fostering an environment that makes compromise with integrity possible. The conditions delineated by Winslow and Winslow include sharing a moral language, mutual respect on the part of those who differ, acknowledgment of factual and moral complexities, and recognition of limits to compromise. In short, when faced with a situation where one is asked to violate one's own sense of morality, dialogue that encompasses the listed conditions may allow moral integrity-preserving negotiation and compromise. Rushton (1995) expanded upon these conditions and applied them to a clinical situation.

Electronic Information

As healthcare service organizations store a greater proportion of their information electronically, new concerns arise for an individual's constitutional right to privacy, as well as a healthcare professional's obligation to uphold confidentiality. Information storage purposes include individual patient record-keeping processes, as well as data collection for organization-wide tracking of trends and establishment of benchmarks, private and governmental healthcare providers' payment calculations, societal health protection, and research investigations.

There are ethical and legal concerns related to the protection of this information. Accrediting organizations such as the JCAHO hold nurses and others in leadership positions accountable for the integrity of stored information, and healthcare organizations are required to demonstrate a balance between security levels and ease of access to electronic information (Styffe, 1997). Thus, it is possible to have an ethical conflict between an individual's right to privacy, a healthcare professional's obligation to protect patient confidentiality, and a third party's right to know certain information. Styffe differentiated between the functions of privacy, confidentiality, and security in protecting electronic information. Privacy refers to the right of individuals to determine when, how, and to what extent information is transmitted (the patient is the primary stakeholder). Confidentiality refers to trust that the information shared will be respected and used only for the purpose disclosed (all healthcare providers and organizations are responsible for confidentiality). Security refers to the protection of information from accidental or intentional access by unauthorized people, including change or destruction of the information, and is a part of the system itself.

Gostin and colleagues (1996) reviewed and commented on the law of health information privacy. State and federal legislation is being developed and revised as information technology evolves and needs for protection are recognized. Nurses need to maintain an awareness of potential changes and rely on the workplace and other professional resources to keep abreast of specific evolving guidelines.

Woodward (1997), Bates (1997), and others (Symposium: Medical Confidentiality & Research, 1997) commented on the use of patient data for research as well as for quality and cost control purposes. According to Bates (p. 112), "Better information systems can make healthcare safer and more efficient, something that is badly needed as the market demands unprecedented improvements in efficiency." He also commented that major changes in policies regarding electronic records and confidentiality are desperately needed, both legislatively and administratively, and at national and local levels. Nurses are likely to be involved (and should be) at all levels, but their input is especially needed at the individual institutional level as integrated delivery systems are initiated. Their sensitivity to privacy and confidentiality as it directly affects individual patients is a vital perspective.

The ANA has developed three position statements related to electronic information: Computer-based Patient Record Standards, Authentication in a Computer-Based Patient Record, and Access to Patient Data. These papers provide background and guidelines related to patient data collection and dispersion. Nurses need to avail themselves of the multiple sources of information related to protection of patient privacy and maintenance of confidentiality as they take control of risk related to the use of electronic data in their practice environments.

Environmental/Occupational Hazards

Nurses may be exposed to a variety of environmental or occupational hazards in their practice. Workplace violence, environmental hazards such as exposure to latex, and the existence of a number of life-threatening communicable diseases stimulate healthcare professionals to consider just how much risk they are obligated to accept as an ethical duty. Sugarman and colleagues (1996) addressed issues of communicable disease in treating patients with multi-drug-resistant tuberculosis, and Smolkin (1997) discussed the risk and duty-to-treat issue in relation to HIV and hepatitis B infections.

Plank I of the ANA Code for Nurses (1985) supports the responsibility of the nurse to provide services with respect for human dignity, unrestricted by a variety of considerations, thus creating a special relationship between the nurse and the client. The nurse is not free to abandon those in need of nursing care. However, the ANA does recognize that there may be limits to the personal risk of harm the nurse can be expected to accept as an ethical duty and has developed a policy on risk versus responsibility in providing nursing care (Position on Risk Versus Responsibility, see ANA Web site). The position provides background information and states, "For assistance in resolving the question of risk versus responsibility, nurses must turn to the field of ethics for guidance. In ethics, the differentiation between benefiting another as a moral duty and benefiting another as a moral option is found in four fundamental criteria. As applied to nursing, a moral obligation exists for the nurse if all four of the following criteria are present:

1. The client is at significant risk of harm, loss, or damage if the nurse does not assist.

2. The nurse's intervention or care is directly relevant to preventing harm.

3. The nurse's care will probably prevent harm, loss, or damage to the client.

4. The benefit the client will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse." Familiarity with these guidelines should help the nurse in decision-making when personal safety is an issue.

Organizations also hold varying degrees of responsibility for workplace safety to their customers and employees. Major ethical principles to consider in managing organizational risk include the best interests of customers and employees and rights to be protected from harm. Information is available in the literature as well as from professional organizations relevant to particular hazards of interest.

Restraints

The underlying ethical issue related to use of physical patient restraints in managing risk is the conflict between an individual patient's autonomy and the healthcare professional's concern for patient safety (best interest, nonmaleficence). For years the justification for the use of restraining devices has been for patient safety; that is, to prevent falls or removal of medical devices such as IVs, endotracheal and nasogastric tubes, and Foley catheters. Additionally, from an institutional viewpoint, there has been a fear that should an unrestrained patient fall and sustain an injury, the institution and/or care provider would be liable for negligence. However, issues of who, when, where, how and, most importantly (from an ethics standpoint) whether to restrain, are extremely complex.

First of all, evidence is not clear that restraint use protects patients from harm. Thus, the use of restraints may not satisfy the ethical principle of acting in the patient's best interest (beneficence, nonmaleficence). While the intention behind the use of restraints historically was for the benefit of the patient, there is ample evidence that indicates more risk of injury from the use of restraints than there are benefits (Marks, 1992). Physical complications associated with the use of restraints include "physical de-conditioning; sensory deprivation; decreased muscle mass, tone and strength; increased osteoporosis; nosocomial infection; urinary and fecal incontinence; skin abrasions; and pressure ulcers" (Marks, p. 2204). Psychological effects of restraint must also be considered.

Capezuti, Evans, Strumpf, and Maislin's (1996) study in long-term care settings likewise revealed that restraint use was not associated with a significantly lower risk of falls. They suggested that researchers and clinicians should focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

In their essay on the ethical and legal aspects of patient restraints, Moss and LaPuma (1991, p. 24) stated, "The Fourteenth Amendment guarantees freedom from harm and unnecessary restraint. The less likely a patient is to cause harm to himself or others, the more significant is the infringement on the patient's legal rights by restraints." Thus, in deciding whether restraints are warranted, professional judgment and knowledge are required. "The issue is not whether to protect the patient; the issue is how to effectively protect the patient in a way that respects the patient's dignity" (What about the Ethics.... 1997, p.9). Informed consent discussion with patients and/or surrogate decision makers are well accepted for other treatment options and should be incorporated into decisions about the use of restraints and other alternatives.

Notice that Moss and LaPuma mentioned the potential for a patient harming others. That can be another legitimate reason to restrain a patient. While restraining an individual may not reduce aggressive or agitated behavior, it can be ethically justifiable when another identifiable individual is at risk of serious morbidity or mortality or the public welfare appears in jeopardy. The ethical principle of preventing harm to identifiable others may supersede the patient's right to refuse. During the last 10 years, efforts have been underway to minimize the use of restraints (Bryant, & Fernald, 1997). The 1987 Omnibus Budget Reconciliation Act (OBRA) and its Interpretive Guidelines, which applied to long-term care, declared that when alternatives to restraints were unsuccessful, then the resident or surrogate must be informed about and consent to the use of restraints. JCAHO has developed standards for restraint practices that have accounted for a high percentage of Type I citations in 1996 and 1997.

It is important to note that rationale for restraint use differs in hospitals as compared with long-term care settings. Mion and colleagues (1996) studied the use of physical restraint in hospital settings, concluding that "the ethical dilemma of autonomy versus beneficence has not been resolved satisfactorily for patients in this setting. The lack of large-scale studies ... makes it difficult for policy makers to determine whether it is necessary to address hospital physical restraint practices through additional regulation" (p. 411). As information accumulates, nurses must continue to update their knowledge base and consider the ethical implications of restraining patients in order to minimize their risk related to this practice.

Summary

Taking control of risk lies squarely within the obligation of ethical conduct for nurses: to provide high-quality nursing care to society and to the individual patient/client. Using moral principles and virtues as a foundation for professional judgment and moral decision making promotes high-quality nursing care and maintains professional and moral integrity while managing risk encourages trust between society and the profession.

References

American Nurses Association. (1985). Code for nurses with interpretive statements. Kansas City, MO: author

American Nurses Association. [Web site]. Home page, reading room, position statements. http://www.nursingworld.org.

American Society for Healthcare Risk Management Code of Professional Responsibility. (1997). ASHRMForum, January/February, 9. Chicago, IL: author.

Bates, D. W. (1997). Commentary: Quality, costs, privacy, and electronic medical data. Journal of Law, Medicine, and Ethics, 25(2&3),111-112.

Beauchamp, I L., & Childress, J. F. (1994). Principles of biomedical ethics, (4th ed.). New York: Oxford University Press.

Bryant, H., & Fernald, L. (1997). Nursing knowledge and use of restraint alternatives: acute and chronic care. Geriatric Nursing, 18(2), 57-60.

Capezuti, E., Evans, L., Strumpf, N., & Maislin, G. (1996). Physical restraint use and falls in nursing home residents. Journal of the American Geriatrics Society, 44(6), 627633.

Christensen, J. R, Levinson, W., & Dunn, P.M. (1992). The heart of darkness: The impact of perceived mistakes. Journal of General Internal Medicine, 7(4), 424-43 1.

Finkelstein, D., Wu, A. W., Holtzman, N. A., & Smith, M. K. (1997). When a physician harms a patient by a medical error: Ethical, legal, and risk-management considerations. The Journal of Clinical Ethics, 8(4), 330-340.

Friedson, J. B. (1997). Must we tell the truth about medical errors? Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 2-4.

Furrow, B. R. (1993). Quality control in healthcare: Developments in the law of medical malpractice. Journal of Law, Medicine, and Ethics,'21(2), 173-192.

Gostin, L. 0., Lazzarini, Z., Neslund, V S., & Osterholm, M. T. (1996). The public health information infrastructure: A national review of the law on health information privacy. Journal of the American Medical Association, 275(24), 1921-1927.

Guido, G. W. (1997). Legal issues in nursing, (2nd ed.). Stamford, CT: Appleton & Lange.

Hafemeister, T. L., & Hannaford, P. L. (1996). Resolving disputes over life-sustaining treatment; A health care provider's guide. Williamsburg, VA: National Center for State Courts.

Howe, E. G. (1997). Possible mistakes. 77ie Journal of Clinical Ethics, 8(4), 323-328.

Leape, L. L. (1997). Can we reduce medical errors? Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 1-2.

Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.

Maintaining ethical conduct throughout an organization. (1997, April). Health System Leader, 26-27.

Marks, W. (1992). Physical restraints in the practice of medicine. Archives of Internal Medicine, 152 (11), 2203-2206.

McFall, L. (1986). Integrity. Ethics, 98, 5-20.

Mion, L. C., Minnick, A., Palmer, R., Kapp, M. B., & Lamb, K. (1996). Physical restraint use in the hospital setting: unresolved issues and directions for research. Milbank Quarterly, 74(3),411-433.

Monagle, J. R (1985). Risk management.- A guide for health care professionals. Rockville, MD: Aspen Systems Corp.

Moss, R. J., & La Puma, J. (1991). The ethics of mechanical restraints. Hastings Center Report, 21(l), 22-25.

Ross, J. W. (1997). Error, ethics, systems, and conflicts. Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 4-5,9.

Rushton, C.H. (1995). The Baby K case: Ethical challenges of preserving professional integrity. Pediatric Nursing, 21(4), 367-372.

Smolkin, D. (1997). HIV infection, risk taking, and the duty to treat. The Journal of Medicine and Philosophy, 22(l), 5574.

Spencer, E. M. (1997). A new role for institutional ethics committees: Organizational ethics. The Journal of Clinical Ethics, 8(4), 372-376.

Styffe, E. J. (1997). Privacy, confidentiality, and security in clinical information systems: Dilemmas and opportunities for the nurse executive. Nursing Administration Quarterly, 21(3), 21-28.

Sugarman, J., Terry, R, Faden, R. R., Holmes, D. E., Fogarty, L., &Pyeritz, R. E. (1996). Professional healthcare workers' attitudes toward treating patients with multidrug-resistant tuberculosis. The Journal of Clinical Ethics, 7(3), 222227.

Sullivan, E. J., & Decker, P. J. (1988). Effective management in nursing (2nd ed.). Menlo Park, CA: Addison-Wesley.

Sweet, M. P., & Bernat, J. L. (1997). A study of the ethical duty of physicians to disclose effors. The Journal of Clinical Ethics, 8(4), 341-348.

Symposium: medical confidentiality &research. (1997). The Journal of Law, Medicine, and Ethics, 25(2&3),85-138.

What about the ethics of restraint use?(1997). Ethical Currents, A Publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 50 (Summer), 8-9.

Winslow, B. J., & Winslow, G. R. (199 1). Integrity and compromise in nursing ethics. The Journal of Medicine and Philosophy, 16,307-323.

Witman, A. B., Park, D. M., & Hardin, S. B. (1996). How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Archives of Internal Medicine, 156(22), 2565-2569.

Woodward, B. (1997). Medical record confidentiality and data collection. The Journal of Law, Medicine, and Ethics, 25(2&3), 88-97.

JoAnn B. Reckling, PhD, RN is an ethics consultant in Fort Collins, Colorado. Robin Welsh, JD, RN is Patient Representative/Risk Management Assistant, Poudre Valley Hospital, Fort Collins, Colorado.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

American Nurses Association (2001). The code of ethics for nurses with interpretive statements. Washington, D.C., American Nurses Publishing.

Kopala, B., Kondratowicz, D.M., Goldberg, A.L., Panek, D.M. (October 1999). Home health care professionals at risk of harm. Home Care Provider, 4 (5), 193-7.

Wysoker, A. (October 1999). Legal and ethical considerations. Suicide: risk management strategies. Journal of American Psychiatric Nurses Association, 5 (5), 164-6.

Appendix I

ANA Code For Nurses

(reprinted with permission of the American Nurses Association)

1. The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

2. The nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.

3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.

4. The nurse assumes responsibility and accountability for individual nursing judgments and actions.

5. The nurse maintains competence in nursing.

6. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others.

7. The nurse participates in activities that contribute to the ongoing development of the profession's body of knowledge.

8. The nurse participates in the profession's efforts to implement and improve standards of nursing.

9. The nurse participates in the profession's efforts to establish and maintain conditions of employment conducive to high quality nursing care.

10. The nurse participates in the profession's effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.

11. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.

Appendix II

(reprinted with permission of the American Society for Healthcare Risk Management)

Preamble Healthcare risk management professionals must acknowledge and address multiple and potentially conflicting responsibilities on a daily basis. This involves balancing the needs of employers or clients; patients and visitors; employees, independent contractors and volunteers serving their employers or clients, vendors; fellow healthcare risk management professionals; local, regional, national, and international communities; with their own needs. The healthcare risk management professional must maintain standards of professional conduct which will withstand the scrutiny of all constituencies served.

The American Society for Healthcare Risk Management (ASHRM) issues this Code of Professional Responsibility to assist its members in determining ethically appropriate professional conduct and avoiding conduct which does not meet this standard.

Confidentiality The healthcare risk management professional continually encounters information of a highly confidential nature relating to the business of the employer or client as well as to patients and others served. The healthcare risk management professional must maintain the confidentiality of that information by:

• disclosing confidential information only when such disclosure is required by law; and,

• verifying the appropriate protocols exist or supporting the development of protocols to protect the confidentiality and privacy of patients, employers, clients, and others served, within the scope of the healthcare risk management professional's authority.

Conflict of Interest

A conflict of interest exists when the healthcare risk management professional is called upon to serve competing interests. Some conflicts of interest, such as transactions with a former employer or dealings with past business associates, may be acceptable as long as disclosure of the conflict is made to all involved parties. Other conflicts, such as business transactions which inure to the benefit of the healthcare risk management professional or his/her family members at the expense of others, are unacceptable even if disclosure to all involved parties is made. In order to avoid conflict of interest, the healthcare risk management professional must:

• exercise good faith in all transactions;

• act always for the benefit of the employer or client and avoid any interests, investments or activities which conflict or appear to conflict with the interests of the employer or client;

• make full disclosure of all facts of any transaction which involves possible conflict of interest to all parties involved; and, avoid accepting gifts or other considerations which might unduly influence the healthcare risk management professional's judgment.

Professional Integrity

The healthcare risk management professional must maintain professional integrity at all times by:

• practicing the profession with honesty, fairness, integrity, respect and good faith,
• avoiding conduct which would result in unjust harm to others;
• discharging all professional duties competently and consistently;
• maintaining loyalty to the employer or client and the profession;
• obeying all laws and regulations relating to professional activities, and supporting the development and enforcement of all laws and regulations which enhance the competent and ethical practice of the healthcare risk management profession;
• maintaining and improving professional skills, knowledge and competence through a program of on-going self-assessment and continuing professional education;
• enhancing public understanding of the healthcare risk manage profession;
• assisting in maintaining and raising professional standards in the healthcare risk management profession by supporting research, fostering the professional development of other healthcare risk management professionals, and refraining from participating in any activity that demeans the credibility an dignity of the healthcare risk management profession;
• upholding the mission of the American Society for Healthcare Risk Management; and,
• upholding the integrity of this code of Professional Responsibility by agreeing to abide by all rules of conduct prescribed by this Code and by ASHRM's Bylaws.

Occupational and Environmental Risks in Nursing

Hospitals and other healthcare settings have long been thought to be different than other workplaces - cleaner, safer, healthier. Yet, many healthcare professionals are becoming alerted to the risks posed within their workplace settings, risks to their own health and to the health of the communities they serve. This chapter will provide an overview of environmental health and safety risks in the healthcare industry and focus on two prevalent risks: 1) an occupational health risk - latex exposure, and 2) an environmental risk - hospital waste. Both risks can affect nurses and the clients they care for.

An Overview

The delivery of health care with the approach of the Year 2000 would be unrecognizable to the healthcare providers at the beginning of the Century. Lasers, X-rays, radiation therapy, modem anesthetic methods, even intravenous administration of drugs would have been unimaginable to nursing's collegial predecessors. While healthcare providers have made huge strides in preventing and curing illnesses and in improving the prognosis in those whose illnesses remain incurable, many of the new technologies have created occupational hazards for nurses and other healthcare workers. Some of the anti-neoplastic drugs are carcinogens; many of them pose reproductive hazards for nurses. If these drugs are not prepared and administered carefully, there can be risk of exposure to the carcinogenic properties of the medication.

Anesthetic gases such as nitrous oxide and halogenated anesthetics have been linked to such health problems as impaired fertility; spontaneous abortions; congenital anomalies; hepatic, renal and neurological diseases; depressed immune responses, and increased susceptibility to neo-plastic diseases (Allen, 1996). Interestingly, the room-air levels of anesthetic gases are higher in the recovery room where extubated patients "off-gas," or exhale the anesthetic gases they received during surgery, than in the operating room. Exposure to anesthetic gases may occur in the operating room when there are leaks in endotracheal tubes, poorly fitting patient facial masks, or failure to properly connect the anesthetic waste lines (Rogers, 1991).

Some of the dangers of infectious diseases that existed at the turn of the last century, before antibiotic therapy, are reemerging. Healthcare workers may be at risk of infection when they work with patients who have infectious diseases such as multiple drug-resistant tuberculosis, drug-resistant staphylococcus, and hepatitis. In addition to the biological and chemical hazards to which healthcare workers may be exposed, risks of injury from lifting patients and from workplace violence are at unacceptable levels in the healthcare industry. These workplace hazards put the nurse at.risk. Managing these risks is an important component of a workplace occupational health and safety program.

Latex Risk

Allergies to latex have become a significant occupational health issue. Latex allergy is frequently underestimated and not seriously considered as a risk by many healthcare professionals (Smith, 1993). However, allergic responses can range from the merely irritating runny nose and itchy eyes to life-threatening conditions such as full blown anaphylaxis. In 1987, the Center for Disease Control recommended universal precautions for the prevention of the spread of Hepatitis and Human Immuno-deficiency Virus (HIV). The Occupational Safety and Health Administration's (OSHNs) Blood-borne Pathogens Standard reflects these recommendations. Since the primary universal precaution is the use of gloves, an increased exposure to the latex allergen in healthcare workers has occurred (Susman, 1995). Latex proteins compose about 1.7% of rubber (Yunginger, 1994). Latex proteins leach from rubber gloves into the powder within the gloves and into the hands of the wearer as a result of normal skin moisture. When rubber gloves are donned or removed, latex proteins are discharged into the air exposing those present. Routes of exposure are primarily through cutaneous contact or inspiration.

The American College of Allergy and Immunology has identified healthcare workers who wear latex gloves on a regular basis as being at high risk for developing latex allergy. The predicted percentages for healthcare workers with latex allergy in an early study ranged from three to seventeen percent (Sussman and Beezhold, 1995). In a more recent study, 24% of healthcare workers with a history of atrophy, had a positive skin prick test to latex extract (Sussman and Beezhold, 1995). Of the 24%, approximately one-half were clinically asymptomatic for latex allergy at the time of testing. This represents a large population at risk for latex allergy-related disease and raises the importance of developing comprehensive approaches to risk reduction before severe allergic responses arise.

Some groups of healthcare workers are at greater risk than others. For instance, operating room personnel are at high risk as there is constant glove wearing by multiple people in the operating suite. Patients and healthcare workers can become sensitized to latex through repeated skin or mucous membrane contact, or by inhaling aerosolized glove allergens. Continued exposure to latex allergens increases sensitization and worsens allergic reactions. Contact dermatitis can occur from six to 48 hours after exposure to latex and is characterized by localized redness, swelling, itching, cracking, and fissures of the skin with scaling, vesicles, and open lesions (Gliniecki, 1998). The most dramatic form of latex allergy is immediate and systemic anaphylactic reaction. Symptoms are unmistakable and include a severe generalized skin reaction, upper respiratory symptoms which can escalate to airway obstruction, and a drop in blood pressure. Medical management of anyone who has experienced systernic reactions must include removal of the allergen. Accommodations must be made for allergic employees. For example, the unit to which the employee is assigned could be converted to a latex-free unit. Nurse managers must clearly communicate the accommodations made for the allergic employee to co-workers.

The management of latex allergic employees is an issue in every healthcare institution. Nurses need to know the risks of latex in the healthcare setting to protect themselves, patients, and colleagues.

The American Nurses Association (1996) created the following list of precautions for latex sensitive nurses:

• Avoid all forms of exposure to latex, (i.e., latex sensitive persons must never wear latex gloves)
• Alert physicians, colleagues, and employers of the diagnosis and the need to avoid latex
• Wear a medical alert bracelet and carry emergency medical instructions
• Carry auto-injectable epinephrine
• Carry non-latex gloves
• Make preparations for latex-safe medical care with providers and healthcare facilities

A latex risk assessment should be implemented in all healthcare settings and should include an identification of all places in which latex exposure may occur. Managers should assess employees' perceptions of risk and provide education related to latex allergies and the management of these allergies.

Nurses can be involved in planning education programs related to latex allergy. Education programs should include glove selection, gloving practices, symptoms of latex allergy, and the importance of hand washing (Culver, 1995). Nurses' roles in developing policies for those healthcare workers who are known to be latex sensitive should include assistance with environmental source control, management of symptoms through appropriate referral, and education and communication about workplace accommodation for allergic employees. Finally, nurses should be involved in monitoring latex allergy trends in the workforce (Culver, 1995).

Patients can be exposed to latex through a number of products. Catheters, tubing, drains, intravenous ports, and anesthesia equipment contain latex. Nurses should ask patients about latex allergies, document the allergy in a visible place on the patient record, and alert other healthcare personnel to the allergy. Nurses should monitor patients for latex allergies when using equipment known to contain latex. Nurses can also be instrumental in developing institutional policies for the care of patients with latex allergies.

Latex allergy is a relatively new hazard in the healthcare field. The occupational health team has the most responsibility and the greatest opportunity to influence the health and safety of workers. The occupational health team should be active in developing and implementing comprehensive approaches to hazard identification and elimination. The American Nurses Association has been very active in developing and promoting sound policies regarding latex exposures and is an important source of information for nurses. In addition, two other organizations can provide vital information: ALERT (Allergy to Latex Education and Resource Team, Inc.) and ELASTIC (Education for Latex Allergy Support Team and Information Coalition).

Hospital Waste

While latex exposure is an example of an occupational hazard associated with health care, dioxin and mercury exposures are two environmental hazards related to the healthcare industry. These two hazards are associated with the waste generated by healthcare institutions (Health Care Without Harm, 1998). Dioxin is a known human carcinogen and has been associated with a host of health problems including birth defects, decreased fertility, immune system suppression, and other hormonal disruption. Mercury is a poison that can interfere with the development of the fetal brain, and is directly toxic to the central nervous system, kidneys, and liver in people of all ages.

Dioxin is the common name for a host of similar chemicals that are formed when chlorine -containing products are combusted. Polyvinyl Chloride plastic (PVC) is a major source of the chlorine in medical waste. Plastics comprise 10-15% of the medical waste stream, twice as much as household waste. Once emitted into the air, dioxins become a threat to humans through the food chain. Dioxins can be found in some meats, dairy products, eggs, and fish. Dioxin bioaccumulates in fatty tissue, and can accumulate in human breast milk thereby putting nursing infants at risk of receiving as much as 50 times an adult's exposure dose. Two aspects of dioxin's toxicity are particularly insidious to the public's health: 1) the wide array of health effects including reduced sperm counts, endometriosis, and breast cancer, and 2) the low dosage required to cause adverse effects on health. Additionally, dioxin is extremely persistent in the environment resulting in an ongoing accumulation for current and future generations.

The increase in dioxin risk is associated with HIV/AIDS and Hepatitis infection prevention measures. Universal precautions require that all body fluids be regarded as potentially infectious. This definition encourages the generation of massive amounts of what is believed to be infectious waste. "Red bagging" is the practice of discarding contaminated, infectious waste in red bags earmarked for disposal as regulated medical waste most often in medical waste incinerators. The Environmental Protection Agency (EPA) estimates that there are approximately 2,400 medical waste incinerators in the United States which combust approximately 846 thousand tons of hospital and medical/infectious waste annually (Health Care Without Hann, 1998). The Centers for Disease Control has identified two percent or less of a typical hospital waste stream as pathological waste, (i.e., organs or tissues), which require some form of treatment to protect the public's health. Without a clear understanding of what truly belongs in the category of contaminated medical waste, "red bagging" has been overused in many institutions. Some healthcare institutions place all waste in red bags and incinerate it. The amount of medical waste generated per hospital patient has more than doubled since 1955 (Health Care Without Hann, 1998). This is due, in part, to the use of more plastic and disposable products.

The creation of dioxins can be reduced by not combusting products that contain chlorine including products such as PVC and white paper which is bleached with chlorine to achieve whiteness. Such pollution prevention can be attained through several activities, in many of which nurses can play a vital role. Shaner (1997) suggested that at the point of purchase, many decisions can be made that will ultimately impact on the environment. Shaner (1997) referred to a new set of three R's - reduce, reuse, and recycle. Selecting products that are mercury and PVC free, eliminating unnecessary plastic packaging, buying reusable products, and recycling waste products such as paper can make a huge difference in the environment.

In the clinical setting nurses can play an important part in pollution prevention by properly segregating waste materials, In a New England hospital operating room, two nurses spearheaded a waste reduction project that decreased the volume of regulated waste by 75%. This project resulted in a savings of $30,000 per year in medical waste disposal fees (Shaner, 1997). The nurses worked with infection control staff to ensure safety and appropriate segregation of waste. The Recommended Practices Committee of the Association of Operating Room Nurses (AORN)(1998) developed "Recommended Practices for Environmental Responsibility in the Practice Setting," which can serve as a model for the development of model practices in other clinical settings.

Mercury is the other significant environmental offender associated with hospital waste. Mercury is a heavy metal which is a bioaccumulative and persistent pollutant that is poisonous to humans and wildlife. Once emitted into the environment, it does not break down. In the healthcare setting, mercury can be found in thermometers, blood pressure devices, dilation and feeding tubes, batteries, and fluorescent lamps. Because of the widespread use of these items, mercury may account for 20% of the waste in solid waste streams (Health Care Without Harm, 1998).

Mercury is a potent neurotoxin. Mercury is not destroyed nor changed by incineration. Once emitted by incinerator smokestacks, mercury is deposited on land and surface water. Bacteria can convert elemental mercury to a more biologically available form, methyl mercury. Methyl mercury crosses the placenta, placing the fetus at risk for neurologic damage including psychornotor retardation. Thirty-seven states have some waterways that are so contaminated with mercury that they have been declared unsafe: fish from these lakes, rivers, and streams are unsafe for human consumption.

It is important to note that alternative products exist for all mercury containing products such as light fixtures, for example. A mercury-free healthcare setting would significantly reduce the risks posed by the disposal of mercury. In general, the amount of medical waste can be reduced through the adoption of a pollution prevention approach that integrates healthcare product purchasing and disposal decisions with an emphasis on the use of non-toxic, recyclable, and reusable materials. Waste reduction activities should include the housekeeping and environmental services, purchasing, warehouse and materials management, infectious disease departments, and recycling coordinators (American Society for Healthcare Environmental Services, 1993). Training of all staff in waste recycling and reduction is essential. Nurses, housekeepers, and all members of the healthcare team must know their roles in assigning waste products to the appropriate level of disposal.

Environmentally sound practices are cost effective for hospitals. The Beth Israel Medical Center in New York saves $600,000 per year through product purchasing and disposal modifications, including reducing, reusing and recycling. Guidance for planning such a comprehensive approach is provided by such organizations as the American Society for Health Care Environmental Sciences of the American Hospital Association and the Health Care Without Harm Campaign, a coalition of organizations including the American Nurses Association, the Association of Operating Room Nurses, and other nursing specialty groups. The following nine-step approach adopted by the Health Care Without Harm Campaign (1998) can provide a framework to plan pollution reduction activities in healthcare facilities:

1. Establish a "green team" including administrators, housekeepers, engineers, and those handling waste to identify the waste stream of the facility and how it is disposed, and to identify a waste management strategy that includes waste reduction, reuse, and recycling measures
2. Assign a full-time person to be in charge of the waste management program.
3. Train staff about the environmental consequences of medical waste incineration and better waste management practices.
4. Explore fully the recycling of products and do not incinerate what can be recycled. Communicate with suppliers about the need for recyclable and reusable products and packaging materials.
5. Use reusable products over disposable ones and do not incinerate what can be reused.
6. Use other, safer disposal methods such as autoclaving and microwaving when possible in lieu of incineration.
7. Begin a program to eliminate products containing mercury.
8. Create a plan to reduce chlorine-containing products such as PVCs.
9. Assign materials management staff to communicate with suppliers concerning the need to buy environmentally preferable products, including cleaning products, biocides, and other chemicals that help reduce the overall use of toxic chemicals.

Summary

The public will come to better understand the environment and its impact on health. Nurses and other healthcare workers are increasingly aware of the personal health and safety risks in the employment setting. As a result, the healthcare industry and healthcare practitioners will be held accountable to reduce the risks posed to the people they employ and the communities they serve.

The registered nurse will become an ever more vital link in limiting occupational and environmental risks in the practice setting. Appropriate education, thoughtful precautions in practice, and careful management of health and safety risks in the workplace can ensure that healthcare settings are cleaner, safer, and healthier places for the nurse and the populations they care for.

References

Allen, A., & Badgewell, M.J. (1996). The post anesthesia care unit: Unique contribution, unique risk. Journal of Perianesthesia Nursing, 2 (4), 248-258.

American Nurses Association. (1996). Latex allergy: Protect yourself, protect your patients. Workplace Information Series. Washington, DC: American Nurses Association.

Association of Operating Room Nurses. (1998). Standards, recommended practices and guidelines. Denver, CO: Association of Operating Room Nurses

Culver, B.I. (1995). Latex sensitivity in healthcare workers: Reality, risk and remedy. Journal of the Association of Occupational Health Professionals in Healthcare, 9 (3), 2-11.

Culver, J. (1995). Latex sensitivity in healthcare workers. Journal of the Association of Occupational Health Professionals in Healthcare, 9 (3), 2-11.

Gliniecki, C. (1998). Management of latex reactions in the occupational setting. Journal of the American Association of Occupational Health Nurses, 46 (2), 82-92.

Health Care Without Harm, The Campaign for Environmentally Responsible Health Care. (1998). Healing the harin, a handbook. Washington, DC: Health Care Without Harm, The Campaign for Environmentally Responsible Health Care.

Jackson, D. (1995). Latex allergy and anaphylaxis - What to do? Journal of Intravenous Nursing, .1 (18), 33-50.

McRae, G., Shaner, H., & Bisson, C.L. (1993). An ounce of prevention: Waste reduction strategies for health care facilities. Chicago, EL: American Society for Healthcare Environmental Services of the American Hospital Association.

Rogers, B., & Travers, P. (1991). Occupational hazards of critical care nursing: Overview of work related hazards in nursing-health and safety issues. Heart and Lung, 20, 486499.

Shaner, H. (1997). Environmentally responsible clinical practice: Clinician's role in waste management. Washington, DC: Health Care Without Harm, The Campaign for Environmentally Responsible Health Care.

Smith, S., Tyndall, J., & Young, A. (1993). Do you have a latex allergy protocol? Canadian Operating Room Nursing Journal, 11 (3), 26-28.

Sussman, G., & Beezhold, D. (1995). Allergy to natural rubber latex. Unpublished manuscript. Rochester, MN.

Barbara Sattler, DrPH, RN, is Director of the Environmental Health Education Center in the School of Medicine at the University of Maryland Dr Sattler acknowledges the assistance of Becky Hess, BSN, RN, in preparing this chapter

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Aufseeser_Weiss, M.R., Ondeck, D.A. (June 2001). Medication use risk management: hospital meets home care. Journal of Nursing Care Quality, 15 (2), 50-7.

Fragala, G. (November 2000). A guide to developing an ergonomics program. Hospital Employee Health.19 (11), 127-129, 132.

Hood, J. (June 2000). Is "latex safe" possible? Using a systematic approach in occupational health. AAOHN Journal 48 (6), 291-296.

Karvonen, C.A. (November 1999). Latex allergy in health care workers: what are the risks? AAOHN Journal 47 (11), 519-525.

Kohn, P. (January 1999). Legally speaking. The legal implication of latex allergy. RN, 62 (1), 63-5.

Miller, K.K. (June 2000). Research based prevention strategies: management of latex allergy in the workplace. AAOHN Journal, 48 6, 278-90.

Strinko, J.M., Howard, C.A., Schaeffer, S.L., Laughlin, J.A., Berry, M.A. Turner, S.N. (June 2000). Reducing risk with telephone followup of patients who leave against medical advice or fail to complete and ED visit. Journal of Emergency Nursing, 26 (3), 223-32, 282-288.

Attachment #1

Common Insurence and Legal Terms

ABANDONMENT: Leave or give up a duty owed to another.

ACCIDENT: Unforeseen and unintended event or occurrence.

ACCREDITATION: A credential given to an agency or institution upon meeting a certain set of standards.

ACTUARY: A person trained in the mathematics of insurance such as the calculation of premiums, reserves, life expectancy and other values.

ADMINISTRATIVE LAW: The law created by administrative agencies of government. For example, laws made by the state boards of nursing.

ADMINISTRATOR: Companies responsible for issuing insurance policies, billing and collecting premiums, providing customer service and marketing insurance programs. For example, Maginnis and Associates, a Division of Kirke-Van Orsdel, Inc. is an insurance administrator.

ADVANCED DIRECTIVES: Instructions and desires regarding health care treatment stated by a competent adult. These instructions can be issued through spoken word, power of attorney