Norma Ellis is a 76 year old widow, who recently had a fall at the nursing
home she has lived in for the past 7 years and fractured her hip. She has subsequently has a
hip replacement and has been rehabilitating well and is now due for discharge back to the
nursing home. Norma has an extensive medical history including postural hypotension,
rheumatoid arthritis, and impaired mobility. She mobilised within the nursing home using
a walker. Her son is demanding that his mother be kept in the ward as an inpatient as he
feels that the nursing home staff were negligent and wants his mother to be placed
elsewhere bus has not arranged this yet. The treating team consist of the doctor,
physiotherapist, nurse unit manager of the rehabilitation unit, social worker, and nurse
unit manager of the Norma’s ward at nursing home, where she was in prior to the fall. You
are the designated team leader. The doctor feels that there is no need to have Mrs. Ellis on
the ward as he feels that her rehabilitation has been maximised, this is an opinion shared
by the physiotherapist. Norma wants to go back to the nursing home as she has made many
friends there and feels at home there.
Discuss the following question with rationales,
Question: – what were the key issues in this dilemma?
Question: – How would you deal with Norma’s son?
Question :-Are his objection warranted?
Ethical Dilemma
An ethical dilemma results when there are two alternatives and neither is right or wrong.
The decision which would have maximum benefit to the patient depends on the circumstances
during the occurrence of the ethical dilemma (Wilson, 2012). During the occurrence of an ethical
dilemma, the nurse has to make the most appropriate choice between two options. In some
situations, an ethical dilemma seems to have been solved. However, there are some questions
which still remain unanswered and as a result, this ambiguity possesses a challenge to the person
who makes the decision (Nursing and Midwifery Board of Australia, 2012).
Therefore, a nurse has to make a decision basing on ethical principles and theories. To
reason ethically, the nurse must think critically of what should be done in an orderly and
systematic manner to provide a rationale of actions based on the ethical principles (Nursing and
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Midwifery Board of Australia, 2012). However, it should be clear to the nurse involved that the
decision to be made should not entirely be based on intuitions and emotions.
Once the ethical dilemma is identified, the nurse should determine the main issues in the
dilemma to be able to come up with the best resolution. Some of the factors that should be
considered include ethical theories and principle, the party to be affected and the consequences
of the alternatives. For a nurse to be able to resolve an ethical dilemma, it is important to make
her decisions in a systematic manner.
The key issues that have come out from Norma’s case include: the son wants her mother
to be retained in the ward since he feels the mother got the fracture from the negligence of the
staff working in the nursing home. However, it is not justified that she indeed got the fracture as
a result of negligence. Another issue that comes out clearly is that Norma wants to go back to the
nursing home due to the friends that she had made at the nursing home.
One of the ethical principles in nursing is autonomy. The patient has a right to make
decisions regarding her treatment. However, the nurse is obliged to intervene if at all she feels it
is not the best decision the patient has made. Also, the principle of beneficence stipulates that
nurses are obliged to do good and no harm. Therefore, as a nurse-in-charge of the ward, I would
weigh the two options so as to be able to make a decision that would most benefit Norma.
In this case, as the team leader in the management of Mrs. Noma’s case, I would explain
to the son that her mother had a right to be allowed to make decisions regarding her treatment
(Burkhardt & Nathaniel, 2013). In addition, I would explain that old age is one of the risk
factors for fractures due to reduced calcification.
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Mrs. Noma’s son’s objections are not warranted. This is because there is no clear evidence
that the team in the rehabilitation center played a role in the fracture that Norma sustained during
her stay in the Nursing home. Therefore, there was no clear reason as to why the patient could
not be taken to the nursing home. From the issues raised above, it is so clear that some ethical
issues have come out openly. Therefore the nurse responsible for handling the issues should be in
a position to apply the relevant moral knowledge to be in a position to make the most beneficial
decision for the patient (Berman et al.).
References
Berman, A., Snyder, S.J., Kozier, B., Erb, G., Levett-Jones T., Dwyer, T., Hales, M., Harvey, N., &
Stanley, D. (2013). Kozier and erb’s fundamentals of nursing (2nd ed.). Vol 2, NSW:
Pearson Sydney Australia.
Burkhardt, M. A., & Nathaniel, A. (2013). Ethics and issues in contemporary nursing. Cengage
Learning..
DeKeyser Ganz, F., & Berkovitz, K. (2012). Nurses’ perceptions of ethical dilemmas, moral distress
and quality of care. Journal of Advanced Nursing, 68(7), 1516-1525.
Faden, R. R., Beauchamp, T. L., & Kass, N. E. (2014). Informed consent, comparative effectiveness,
and learning health care. N Engl J Med, 370(8), 766-768.
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González-Pachón, J., & Romero, C. (2016). Bentham, Marx and Rawls ethical principles: In search
for a compromise. Omega, 62, 47-51.
Hunt, L., Ramjan, L., McDonald, G., Koch, J., Baird, D., & Salamonson, Y. (2015). Nursing students’
perspectives of the health and healthcare issues of Australian Indigenous people. Nurse
education today, 35(3), 461-467.
Kangasniemi, M., Pakkanen, P., & Korhonen, A. (2015). Professional ethics in nursing: an
integrative review. Journal of advanced nursing, 71(8), 1744-1757.
Lee, J. Y., & Divaris, K. (2014). The ethical imperative of addressing health disparities in a unifying
framework. Journal of dental research, 93(3), 224-230.
Myers, M. D., & Venable, J. R. (2014). A set of ethical principles for design science research in
information systems. Information & Management, 51(6), 801-809.
Nursing and Midwifery Board of Australia. (2013). Nursing and national competency standards for
Registered nurse. .
Wilson, R. (2012). Legal, ethical and professional concepts with in the operating department.
National Institute of Health, 22(3),81-5.
Registered nurse (RN) practice is person-centred and evidence-based with preventative, curative,
formative, supportive, restorative and palliative elements. RNs work in therapeutic and professional
relationships with individuals, as well as with families, groups and communities. These people may be
healthy and with a range of abilities, or have health issues related to physical or mental illness and/or
health challenges. These challenges may be posed by physical, psychiatric, developmental and/or
intellectual disabilities.
The Australian community has a rich mixture of cultural and linguistic diversity, and the Registered nurse
standards for practice are to be read in this context. RNs recognise the importance of history and culture
to health and wellbeing. This practice reflects particular understanding of the impact of colonisation on the
cultural, social and spiritual lives of Aboriginal and Torres Strait Islander peoples, which has contributed to
significant health inequity in Australia.
As regulated health professionals, RNs are responsible and accountable to the Nursing and Midwifery
Board of Australia (NMBA). These are the national Registered nurse standards for practice for all RNs.
Together with NMBA standards, codes and guidelines, these Registered nurse standards for practice
should be evident in current practice, and inform the development of the scopes of practice and
aspirations of RNs.
RN practice, as a professional endeavour, requires continuous thinking and analysis in the context of
thoughtful development and maintenance of constructive relationships. To engage in this work, RNs need
to continue to develop professionally and maintain their capability for professional practice. RNs
determine, coordinate and provide safe, quality nursing. This practice includes comprehensive
assessment, development of a plan, implementation and evaluation of outcomes. As part of practice, RNs
are responsible and accountable for supervision and the delegation of nursing activity to enrolled nurses
(ENs) and others.
Practice is not restricted to the provision of direct clinical care. Nursing practice extends to any paid or
unpaid role where the nurse uses their nursing skills and knowledge. This practice includes working in a
direct non-clinical relationship with clients, working in management, administration, education, research,
advisory, regulatory, policy development roles or other roles that impact on safe, effective delivery of
services in the profession and/or use of the nurse’s professional skills. RNs are responsible for
autonomous practice within dynamic systems, and in relationships with other health care professionals.
How to use these standards
The Registered nurse standards for practice consist of the following seven standards:
- Thinks critically and analyses nursing practice.
- Engages in therapeutic and professional relationships.
- Maintains the capability for practice.
- Comprehensively conducts assessments.
- Develops a plan for nursing practice.
Registered nurse standards for practice
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- Provides safe, appropriate and responsive quality nursing practice.
- Evaluates outcomes to inform nursing practice.
The above standards are all interconnected (see Figure 1). Standards one, two and three relate to each
other, as well as to each dimension of practice in standards four, five, six and seven.
Figure 1: Registered nurse standards
Each standard has criteria that specify how that standard is demonstrated. The criteria are to be
interpreted in the context of each RN’s practice. For example, all RNs will, at various times, work in
partnerships and delegate responsibilities, however not every RN will delegate clinical practice to enrolled
nurses. The criteria are not exhaustive and enable rather than limit the development of individual
registered nurse scopes of practice.
The Registered nurse standards for practice are for all RNs across all areas of practice. They are to be
read in conjunction with the applicable NMBA companion documents such as the standards, codes and
guidelines, including the Code of professional conduct for nurses, Code of ethics for nurses, National
framework for the development of decision-making tools for nursing and midwifery practice, Supervision
guidelines for nursing and midwifery, and Guidelines for mandatory notifications. The glossary is also
important for understanding how key terms are used in these standards.
Registered nurse standards for practice
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Registered nurse standards for practice
Standard 1: Thinks critically and analyses nursing practice
RNs use a variety of thinking strategies and the best available evidence in making decisions and providing
safe, quality nursing practice within person-centred and evidence-based frameworks.
The registered nurse:
1.1 accesses, analyses, and uses the best available evidence, that includes research findings, for safe,
quality practice
1.2 develops practice through reflection on experiences, knowledge, actions, feelings and beliefs to
identify how these shape practice
1.3 respects all cultures and experiences, which includes responding to the role of family and community
that underpin the health of Aboriginal and Torres Strait Islander peoples and people of other cultures
1.4 complies with legislation, regulations, policies, guidelines and other standards or requirements
relevant to the context of practice when making decisions
1.5 uses ethical frameworks when making decisions
1.6 maintains accurate, comprehensive and timely documentation of assessments, planning, decision-
making, actions and evaluations, and
1.7 contributes to quality improvement and relevant research.
Standard 2: Engages in therapeutic and professional relationships
RN practice is based on purposefully engaging in effective therapeutic and professional relationships. This
includes collegial generosity in the context of mutual trust and respect in professional relationships.
The registered nurse:
2.1 establishes, sustains and concludes relationships in a way that differentiates the boundaries between
professional and personal relationships
2.2 communicates effectively, and is respectful of a person’s dignity, culture, values, beliefs and rights
2.3 recognises that people are the experts in the experience of their life
2.4 provides support and directs people to resources to optimise health-related decisions
2.5 advocates on behalf of people in a manner that respects the person’s autonomy and legal capacity
2.6 uses delegation, supervision, coordination, consultation and referrals in professional relationships to
achieve improved health outcomes
2.7 actively fosters a culture of safety and learning that includes engaging with health professionals and
others, to share knowledge and practice that supports person-centred care
2.8 participates in and/or leads collaborative practice, and
2.9 reports notifiable conduct of health professionals, health workers and others.
Standard 3: Maintains the capability for practice
RNs, as regulated health professionals, are responsible and accountable for ensuring they are safe, and
have the capability for practice. This includes ongoing self-management and responding when there is
concern about other health professionals’ capability for practice. RNs are responsible for their professional
development and contribute to the development of others. They are also responsible for providing
information and education to enable people to make decisions and take action in relation to their health.
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The registered nurse:
3.1 considers and responds in a timely manner to the health and wellbeing of self and others in relation
to the capability for practice
3.2 provides the information and education required to enhance people’s control over health
3.3 uses a lifelong learning approach for continuing professional development of self and others
3.4 accepts accountability for decisions, actions, behaviours and responsibilities inherent in their role,
and for the actions of others to whom they have delegated responsibilities
3.5 seeks and responds to practice review and feedback
3.6 actively engages with the profession, and
3.7 identifies and promotes the integral role of nursing practice and the profession in influencing better
health outcomes for people.
Standard 4: Comprehensively conducts assessments
RNs accurately conduct comprehensive and systematic assessments. They analyse information and data
and communicate outcomes as the basis for practice.
The registered nurse:
4.1 conducts assessments that are holistic as well as culturally appropriate
4.2 uses a range of assessment techniques to systematically collect relevant and accurate information
and data to inform practice
4.3 works in partnership to determine factors that affect, or potentially affect, the health and wellbeing of
people and populations to determine priorities for action and/ or for referral, and
4.4 assesses the resources available to inform planning.
Standard 5: Develops a plan for nursing practice
RNs are responsible for the planning and communication of nursing practice. Agreed plans are developed
in partnership. They are based on the RNs appraisal of comprehensive, relevant information, and
evidence that is documented and communicated.
The registered nurse:
5.1 uses assessment data and best available evidence to develop a plan
5.2 collaboratively constructs nursing practice plans until contingencies, options priorities, goals, actions,
outcomes and timeframes are agreed with the relevant persons
5.3 documents, evaluates and modifies plans accordingly to facilitate the agreed outcomes
5.4 plans and negotiates how practice will be evaluated and the time frame of engagement, and
5.5 coordinates resources effectively and efficiently for planned actions.
Standard 6: Provides safe, appropriate and responsive quality nursing practice
RNs provide and may delegate, quality and ethical goal-directed actions. These are based on
comprehensive and systematic assessment, and the best available evidence to achieve planned and
agreed outcomes.
The registered nurse:
6.1 provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are
responsive to the nursing needs of people
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6.2 practises within their scope of practice
6.3 appropriately delegates aspects of practice to enrolled nurses and others, according to enrolled
nurse’s scope of practice or others’ clinical or non-clinical roles
6.4 provides effective timely direction and supervision to ensure that delegated practice is safe and
correct
6.5 practises in accordance with relevant policies, guidelines, standards, regulations and legislation, and
6.6 uses the appropriate processes to identify and report potential and actual risk related system issues
and where practice may be below the expected standards.
Standard 7: Evaluates outcomes to inform nursing practice
RNs take responsibility for the evaluation of practice based on agreed priorities, goals, plans and
outcomes and revises practice accordingly.
The registered nurse:
7.1 evaluates and monitors progress towards the expected goals and outcomes
7.2 revises the plan based on the evaluation, and
7.3 determines, documents and communicates further priorities, goals and outcomes with the relevant
persons.
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Glossary
These definitions relate to the use of terms in the Registered nurse standards for practice.
Accountability means that nurses answer to the people in their care, the nursing regulatory authority,
their employers and the public. Nurses are accountable for their decisions, actions, behaviours and the
responsibilities that are inherent in their nursing roles including documentation. Accountability cannot be
delegated. The registered nurse who delegates activities to be undertaken by another person remains
accountable for the decision to delegate, for monitoring the level of performance by the other person, and
for evaluating the outcomes of what has been delegated (Nursing and Midwifery Board of Australia 2013).
See below for the related definition of ‘Delegation’.
Criteria in this document means the actions and behaviours of the RN that demonstrate these standards
for practice.
Delegation is the relationship that exists when a RN delegates aspects of their nursing practice to another
person such as an enrolled nurse, a student nurse or a person who is not a nurse. Delegations are made
to meet peoples’ needs and to enable access to health care services, that is, the right person is available
at the right time to provide the right service. The RN who is delegating retains accountability for the
decision to delegate. They are also accountable for monitoring of the communication of the delegation to
the relevant persons and for the practice outcomes. Both parties share the responsibility of making the
delegation decision, which includes assessment of the risks and capabilities. In some instances delegation
may be preceded by teaching and competence assessment. For further details see the NMBA’s National
framework for the development of decision-making tools for nursing and midwifery practice (2013).
Enrolled nurse is a person who provides nursing care under the direct or indirect supervision of a
registered nurse. They have completed the prescribed education preparation, and demonstrate
competence to practise under the Health Practitioner Regulation National Law as an enrolled nurse in
Australia. Enrolled nurses are accountable for their own practice and remain responsible to a registered
nurse for the delegated care.
Evidence-based practice is accessing and making judgements to translate the best available evidence,
which includes the most current, valid, and available research findings into practice.
Person or people is used in these standards to refer to those individuals who have entered into a
therapeutic and/or professional relationship with a registered nurse. These individuals will sometimes be
health care consumers, at other times they may be colleagues or students, this will vary depending on
who is the focus of practice at the time. Therefore, the words person or people include all the patients,
clients, consumers, families, carers, groups and/or communities that are within the registered nurse scope
and context of practice. The registered nurse has professional relationships in health care related teams.
Person-centred practice is collaborative and respectful partnership built on mutual trust and
understanding through good communication. Each person is treated as an individual with the aim of
respecting people’s ownership of their health information, rights and preferences while protecting their
dignity and empowering choice. Person-centred practice recognises the role of family and community with
respect to cultural and religious diversity.
Registered nurse is a person who has completed the prescribed education preparation, demonstrates
competence to practise and is registered under the Health Practitioner Regulation National Law as a
registered nurse in Australia.
Scope of practice is that in which nurses are educated, competent to perform and permitted by law. The
actual scope of practice is influenced by the context in which the nurse practises, the health needs of
people, the level of competence and confidence of the nurse and the policy requirements of the service
provider.
Standards for practice in this document are the expectations of registered nurse practice. They inform
the education standards for registered nurses, the regulation of nurses and determination of the nurse’s
capability for practice, and guide consumers, employers and other stakeholders on what to reasonably
expect from a registered nurse regardless of the area of nursing practice or years of nursing experience.
They replace the previous National competency standards for the registered nurse (2010).
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Supervision includes managerial supervision, professional supervision and clinically focused supervision.
For further details see the NMBA’s, Supervision guidelines for nursing and midwifery (2015).
Therapeutic relationships are different to personal relationships. In a therapeutic relationship the nurse
is sensitive to a person’s situation and purposefully engages with them using knowledge and skills in
respect, compassion and kindness. In the relationship the person’s rights and dignity are recognised and
respected. The professional nature of the relationship involves recognition of professional boundaries and
issues of unequal power. For further details see the NMBA’s A nurse’s guide to professional boundaries
(2010).