In the mid 1970s, a nursing educator in Idaho had contact, through a student, with a female client who had chronic myelogenous leukemia. This form of leukemia can often be managed for years with little or no chemotherapy. The woman had done well for about twelve years and ascribed her good condition to health foods and a strict nutritional regime. However, her condition had turned worse several weeks before and her physician had advised her that she needed chemotherapy if she were to have any chance at survival. The physician had also advised her of the potential side effects of the therapy including hair loss, nausea, fever, and immune system suppression.
The woman consented to the therapy and signed the appropriate forms, but later, she began to have second thoughts. The nursing educator and student had given the patient one dose of the therapy when the woman began to cry and express her reservations about the therapy. She questioned the nurse about alternative treatments to the use of chemotherapy. The patient related that she had accepted the therapy because her son had advised her that this was the best treatment. She related that she had not asked about alternate forms of treatment as the physician had indicated that chemotherapy was the only treatment indicated. The nurse did not discuss the patient’s concerns with the physician, and later that evening, she talked to the patient about alternate therapies. In the discussion, rather nontraditional and controversial therapies were covered including reflexology and the use of laetrile. During the talk, the nurse made it very clear that the treatments under discussion were not sanctioned by the medical community.
The patient’s feelings toward alternate therapies were strengthened by the evening’s conversation; however, she continued with chemotherapy. The treatments, however, did not bring remission to her crisis and she died two weeks later. Upon hearing about the conversation between the off duty nurse educator and his patient, the physician brought charges against the nurse for unprofessional conduct and interfering with the patient-physician relationship. (In re Tuma,1977).
Vicarious liability is the liability an organization holds for its employees (Rodriguez, 2009). It is the shared or shifted responsibility for another’s actions (Michaels, 2009). In the above scenario, the hospital is responsible for the actions of its staff, including the recommendations of the nursing staff employed by the hospital. In the aforementioned scenario, the nurse discussed with a patient treatments for a life-threatening condition that were not sanctioned by the medical community. These controversial alternatives are not approved or supported by medical professionals; their recommendation should be carefully considered by the healthcare team. Any recommendations made by staff within a professional capacity create vicarious liability for the hospital. The recommendation of unapproved treatments is of additional concern for the hospital as it is outside of the scope of the healthcare safeguards and general standards and practices of the healthcare field.
Within the healthcare field, there are often situations that offer ethical dilemmas. In these situations, it is important to consider not only the standards and regulations, but also the professional code of ethics within the profession. In the aforementioned case, a registered nurse, Jolene Lucille Byerly Tuma, had her professional license suspended for six months following what was determined by the Idaho Board of Nursing as well as the district court to be unprofessional conduct;the hearing officer found that Tuma’s behavior interfered with the provider-patient relationship and therefore constituted unprofessional conduct (LSU, 1998; VersusLaw, Inc. 2009). By taking it upon herself to offer information on alternatives to the treatment prescribed by the physician, Tuma potentially undermined the provider’s status with the patient.
The Idaho Board of Nursing states that within the practice, a nurse shall observe and report to the necessary party any significant changes in the patients’ condition; within the context of professional behavior a nurse must maintain professional boundaries that respect not only the patient, but also the nurse’s coworkers (IAC, 2009). In this situation, the nurse did not report the significant emotional changes of the patient to the appropriate party: the physician was not informed by the nurse as to the patient’s status. In this manner, Tuma did not fulfill the standards of the nursing profession or the requirements of the Idaho Board of Nursing. Also, the omission of the provider in the process of addressing the patient’s concerns exceeded the professional boundaries of the situation and did not maintain intraprofessional integrity.
According to the ANA’s Code of Ethics (2005), the nurse has a professional obligation to collaborate with the healthcare team. This specifies not only cooperation, but ensuring that the relationship with other healthcare providers is clearly represented. To fulfill this professional duty, there must be mutual trust, recognition and respect. By discussing treatment options with the patient, the nurse suspended not only the provider-patient relationship, but also invalidated the trust, respect and recognition demanded by the nature of her profession.
Especially during this crucial and life threatening situation, it is the nurse’s responsibility to report concerns to the provider; by failing to report the patient’s concerns, reservations and emotional state with the provider, the nurse did not fulfill the expectations of the standard of the nursing profession. In this case, the nurse erred in omitting the provider from the discussion. Following the professional codes and ethics, one would inform the provider of the patient’s concerns and address the concerns as a team, following mutual respect and trust. By failing to fulfill the necessary reporting, the nurse also failed to honor the collaborative relationship of the healthcare team.
One would conclude that the nurse, by transitioning from following treatment orders of the physician to discussing treatment options, had exceeded her scope of practice. The limits of the nursing practice dictate that certain areas of patient care are directed to the physician; the collaboration within the team indicates that the nurse is not the appropriate director of nursing care.
Under the patient advocate role, the nurse’s actions are still unjustified because she violated the hierarchal structure of the healthcare system by omitting the provider from the discussion. Had she informed the physician of the patient’s concerns and arranged to address those concerns as a patient advocate with the physician, her actions of discussing the alternative treatments may have been justifiable under the patient advocate portion of her nursing description.
The appellate court later reversed the decision, stating that the guidelines dictating unprofessional conduct were not clear enough such that an average person would understand the nature of unprofessional conduct (LSU, 1998; VersusLaw Inc. 2009). However, in this scenario, one would likely find that the nurse violated the professional code of conduct by failing to inform the physician of the patient’s concerns. This failure resulted in a detrimental effect to the provider-patient relationship, and the professional boundaries and collaboration was diminished. Given that the provider-patient relationship was damaged, as well as the intraprofessional relationship, the nurse should be sanctioned due to unprofessional and unethical conduct. Another contributing factor to the decision to sanction the nurse is the vicarious liability brought about through her actions. The hospital could be held liable for the recommendations of the nurse; this liability is increased by the unauthorized and non-endorsed alternatives that were recommended. As a nurse, Tuma has a responsibility to the patient as well as to the hospital; in this case, these interests did not conflict. By overstepping the scope of nursing practice, she not only negatively impacted the hospital, provider, but also interfered with the patient’s treatment. These actions necessitate sanctioning because of their significant negative and unethical impact.