Solo Nurse in the Emergency Department

A 24-year-old man arrives in the small community emergency department in the middle of the night with epistaxis (nosebleed). The nursing staff are the only ones present in the hospital. (This situation is common in many small communities in the United States.) The senior nurse applies direct pressure to the nose, but after five minutes the bleeding has not stopped, so she contacts the physician-on-call.

He advises the nurse to repeat the procedure and, at the end of another five-minute period, to release the patient. (This would be inappropriate if it could not be demonstrated that the bleeding had stopped.) Should the nurse demand that the physician come in? Should she call someone else (even though he is not on duty)? Or should she just do what was suggested? Would she actually be practicing medicine without a license — and against her will?


Commentary

This case presents a common dilemma for nurses both in emergency and non­emergency situations. The larger ethical and legal question is: What should the nurse do to meet her obligation to the patient? And the answer to that larger question depends on several factors: the clinical picture, the legal boundary between nursing and medical practice, the ethical obligations of the nurse, and the established professional norms in this type of emergency situation.

We and the nurse, Ms. Stevens, need to know more about the patient, Mr. Bennet, clinically. Such data as his history and his family history plus his vital signs and any other symptoms he may have (whether he has recently experienced any trauma to the face or head, whether he is on drugs and, if so, which one(s), whether he has been in an emotionally upsetting situation in the last few hours, etc.) must be gathered in order to assess the clinical picture.


Some of these data will be difficult to collect from a patient whose nose is bleeding, so Ms. Stevens will have to work out a way of gathering them in the least intrusive manner. While a nosebleed is not usually perceived to be as serious as, for example, a stab wound, it can be the first sign of a serious condition. Also, Mr. Bennet is sufficiently worried and perhaps frightened to come to the emergency de­partment in the middle of the night. He thinks it is serious.

Therefore, even though this is not as dramatic as scenes from TV hospital programs would have us believe the emergency room to be, Mr. Bennet must not be viewed as a nonemergency. This is true even though the emergency department is often the only place to go for help in a small community in the middle of the night.

The second factor to be considered is the legal boundary of nursing practice. The line between nursing and medical practice has become blurred. In some cases, nurses and doctors have difficulty in differentiating those tasks that are strictly medical from those that are legitimately within the realm of nursing. The knowledge explosion coupled with the technological advances and social changes have necessitated redefinition of the scope of nursing practice.


Between 1971 and 1975, 30 states amended their nurse practice acts to legitimize diagnosis and treatment by nurses, and the trend continues today. The changes in the nurse practice acts are related directly to the need to legalize advanced nursing practice. Nurse practice acts differ across states. And since it is necessary to have the facts about a given situation before one can engage in ethical inquiry, it is important to know the scope of practice as defined in the state where the nurse works.

Nurses have multiple ethical obligations which include obligations to the patient, the hospital, physicians, other nurses, and the profession. The American Nurses' As­sociation Code for Nurses says that the nurse's primary obligation is to the patient. In doing this, the Code places the patient at the center of any ethical controversy but tends to overlook the context of many moral uncertainties that nurses confront.


Many of the most difficult conflicts and uncertainties that nurses experience about their obligations and rights derive from their role as professional employees in a hierarchical structure and about the attending question as to their authority to decide and act in a particular situation. Some of this uncertainty can be eased by knowledge of their state's nurse practice act. However, these acts are often broad in the way they are written and especially in their interpretation.

The established norms for this and many other similar hospital situations is that nurses practice nursing Monday through Friday 7 a.m. to about 4 p.m. They then practice nursing and some medicine the remainder of the time. While this is a well-established norm and more or less understood by all involved, the nurse nevertheless can be in a vulnerable position with both the physician and the hospital if anything goes wrong. At times, it is a case of "damned if you do and damned if you don't."

For example, if the nurse does not call the doctor at 3 a.m., she may be blamed, if there is a need to blame someone. If she does call the physician in the middle of the night, he is not always appreciative of such reliance on his expertise and may not assume his legal and ethical obligation in the case. While many nurses and physicians have a good working rela­tionship with one another, this is not always true. Such a lack of cooperation and coordination, due to numerous complex factors, can develop into a system that feeds on itself and can ultimately be detrimental to the patient.


In the specific case of Mr. Bennet, the nurse, Ms. Stevens, should follow this plan of action: She should do what the physician advised on the phone and apply pressure for another five minutes. If the bleeding stops at this point, Mr. Bennet can be asked to rest for a while, and Ms. Stevens can check on his condition from time to time by asking him specific questions about how he feels (light-headed, etc.) and also can take his vital signs. If further bleeding or other symptoms do not occur, Mr. Bennet can go home, and Ms. Stevens will advise him to call his own physician in the morning.

If the scenario is different and Mr. Bennet's nose continues to bleed even after the second applied pressure, Ms. Stevens must make some decisions that will be grounded in clinical, legal, and ethical considerations. If the data collected by Ms. Stevens do not provide any clues as to possible cause of the nosebleed, she has to decide whether she will phone the on-call physician again or not.


Such a decision will be determined by the clinical factor of the severity of the bleeding, the legal factor as to the boundary of nursing practice defined by the nurse practice act, coupled with the norm or the usual behavior in the place and situation. Obviously, it would be doing harm to discharge the patient under these conditions. Since Ms. Stevens must balance her ethical obligations to both the patient and the physician, she must determine the right thing to do. With her knowledge of this clinical picture, Ms. Stevens decides to try once more with another (the third) five minutes of applied pressure.

If the bleeding stops then, she should follow the same routine as in the scene when the bleeding stopped after the second pressure — which is to have Mr. Bennet rest, to take his vital signs, and to indicate to him the importance of seeing his own physician tomorrow. If, after the third five-minute pressure has been applied, the bleeding has not stopped, Ms. Stevens should phone the on-call physician again and report the situation. Her actions will then depend on the decisions reached on the phone.


After Ms. Stevens provides the physician with all the information she has about Mr. Bennet, he will have to make a decision as to whether to come in or not or whether to have Mr. Bennet stay in the emergency department until someone can see him on the day shift.

If this physician comes in and examines Mr. Bennet, he can then write an order for Mr. Bennet to go home or be admitted to the hospital. Ms. Stevens has met her obligation both to the patient and to the physician. If the decision is to have Mr. Bennet stay in the emergency department until after the day shift arrives, Ms. Stevens has an obligation to report the situation to the day shift. Meanwhile, she needs to make Mr. Bennet as comfortable as possible while keeping a close watch on him.

If, in the first instance, Ms. Stevens finds that Mr. Bennet has high blood pressure, his pulse is irregular, and he has a family history of health problems, she should call the physician at once and insist that he come and examine the patient to decide on a treatment plan and the need for hospitalization.


The on-call physician should be called, since he has a legal and ethical obligation to both the patient and the nurse to practice medicine. It seems most unlikely that the physician under these circumstances would refuse to come in. If he did refuse for some reason, Ms. Stevens has an obligation to take this problem further in the system. This system has the following structure which is similar in most community hospital structures: the night nursing supervisor, the director of nursing, and the "someone else" mentioned in the case who must be another physician, probably the chief of staff.

When a nurse uses the system to put pressure on a physician, she will have to work out the consequences of this action. But if she does not use the system in which she works, she can be viewed as not meeting her legal and ethical obligation to the patient and the hospital.


In thinking about Mr. Bennet's nosebleed, I have tried to draw a line between nursing practice and medical practice, taking into account the clinical, legal, and ethical dimensions. Ms. Stevens, who is a senior nurse with knowledge and experience, can best meet her obligations to Mr. Bennet if she acts on her understanding of these clinical, legal, and ethical dimensions of the case. In order to do this, she must have basic knowledge of these dimensions which means that along with her clinical knowledge she will need to acquire knowledge of the applicable nurse practice act and the norms of practice.

And finally, in order to use all of these, she will need to have reflected on this and other problems so that when the time arrives, she has some general notion of what she ought to do and where she would draw the clinical line between nursing and medicine, the legal line between nurse practice and medical practice, and the ethical line between what are her obligations and those that belong to another health professional.

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