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Title: Designing Advanced Multiselect Assessment Items on Nursing Ethics and Patient Safety for Acute Medical and Geriatric, Multicultural Contexts
Author: Nursing Education Assessment Specialist
Affiliation: Clinical Education and Quality Improvement Unit
Running head: Nursing Ethics and Patient Safety Assessment
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Abstract
This paper presents five advanced, multi-select assessment items designed to evaluate nurses’ integrated clinical judgment regarding ethics and patient safety in acute internal medicine and geriatric care, including multicultural contexts. Items are anchored in realistic clinical scenarios and target informed consent, patient autonomy, confidentiality and interdisciplinary communication, medication double-checks, pressure injury prevention, and SBAR handoffs. Each item includes four options with at least two correct responses, distractors reflecting common frontline misconceptions, explicit answer keys, and brief evidence-based rationales. Item development followed best practices in assessment design, person-centered and non-stigmatizing language, and APA 7th edition documentation standards, with references to established guidelines (e.g., ANA, WHO, CLAS, HIPAA, NPIAP/EPUAP/PPPIA, NICE, ISMP, AHRQ, IHI). These items are intended for training and summative assessment at an advanced (evaluation, synthesis) level.
Keywords: informed consent, autonomy, confidentiality, SBAR, pressure injury prevention, double-checks, multicultural care, advanced assessment
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Introduction
Ethically sound and safe nursing practice requires integrating principles of informed consent, respect for autonomy, confidentiality, and effective interdisciplinary communication with high-reliability safety processes, such as independent double-checks for high-alert medications, pressure injury prevention bundles, and structured handoffs (American Nurses Association [ANA], 2015; Beauchamp & Childress, 2019; Agency for Healthcare Research and Quality [AHRQ], 2017; National Pressure Injury Advisory Panel [NPIAP], European Pressure Ulcer Advisory Panel [EPUAP], & Pan Pacific Pressure Injury Alliance [PPPIA], 2019; World Health Organization [WHO], 2017). In acute internal medicine and geriatric settings, particularly within multicultural populations, patient safety is closely intertwined with ethical decision-making, capacity assessment, linguistic access, and documentation of patient preferences (Appelbaum, 2007; U.S. Department of Health and Human Services [HHS], Office of Minority Health [OMH], 2013; HHS, Office for Civil Rights [OCR], 2013).
This paper develops five advanced, multi-select items for training assessment, emphasizing realistic scenarios, person-centered language, and nuanced prioritization. Each item includes evidence-based rationales and references aligned with best practices.
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Method
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Design approach: Items were constructed to assess higher-order competencies (analysis, synthesis, evaluation) using clinical scenarios representative of acute internal medicine and geriatric care with multicultural contexts. Scenarios and stems were designed to evoke ethical reasoning and safety prioritization without stigmatizing language (ANA, 2015; OMH, 2013).
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Item format: Multi-select with four options and at least two correct responses. Distractors were crafted based on frontline misconceptions and common drift from policy, using three types: near-synonym confusion, conceptual overextension, and inclusion of irrelevant information for the scenario (AHRQ, 2017; ISMP, 2022).
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Content mapping: Items address informed consent and capacity, autonomy and surrogate involvement, confidentiality and minimum-necessary information sharing, double-checks for high-alert medications, pressure injury prevention, and structured SBAR handoffs (Beauchamp & Childress, 2019; NPIAP/EPUAP/PPPIA, 2019; NICE, 2014; IHI, 2017).
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Language standards: Person-centered, gender-neutral terminology; culturally responsive phrasing aligned with CLAS standards; avoidance of absolute statements (OMH, 2013).
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Validation: Content aligned to widely adopted guidelines; rationales include author-year citations. Options were balanced in length and specificity to reduce cueing.
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Results
The following multi-select items are designed for advanced training assessments. Each item includes four options; at least two options are correct. Correct options are labeled, followed by brief evidence-based rationales with citations.
Item 1: Informed consent, capacity, and language access in acute internal medicine
Scenario: A person aged 82 is admitted to the acute medical ward with suspected stroke and fluctuating delirium. They primarily speak Mandarin and understand basic English. A contrasted CT is ordered. Their adult child requests to provide consent and offers to interpret to “save time.”
Which actions most appropriately support informed consent and autonomy within the current clinical context?
A. Arrange a qualified medical interpreter to support communication and assess the person’s understanding before proceeding.
B. Accept the adult child as interpreter without discussing language access options to expedite the process.
C. Evaluate the person’s decision-making capacity; if capacity is insufficient, involve the legally authorized surrogate and document the process.
D. Proceed based on implied consent because the CT is low risk and time is limited.
Correct options: A, C.
Rationale: Use qualified interpreters to promote accurate, equitable communication (OMH, 2013). Capacity is decision- and time-specific; when insufficient, a surrogate may be needed with documentation (Appelbaum, 2007; ANA, 2015; Beauchamp & Childress, 2019). Family members can interpret only after informed preference and when appropriate; defaulting to ad hoc interpreters for convenience reduces fidelity (OMH, 2013). Implied consent typically applies to urgent, life-sustaining interventions when capacity and surrogate consent cannot be obtained; contrasted CT often allows brief capacity assessment and language access (Beauchamp & Childress, 2019).
Item 2: Independent double-checks for high-alert medications
Scenario: A person aged 76 with chronic kidney disease is starting an insulin infusion for hyperglycemia in the acute medical unit. The new nurse asks how to complete the required double-check efficiently.
Which actions best reflect safe practice for high-alert medication administration?
A. Conduct an independent double-check: two clinicians separately verify patient identity, medication, concentration, dose, route, rate, and pump programming against the order and MAR.
B. Request a colleague’s verbal “looks good” while programming the pump together to reduce delays during rounds.
C. Use barcode medication administration for the infusion and complete an independent verification against the order and pump settings.
D. Omit the second check if the pharmacy label indicates “verified” and the order is e-prescribed.
Correct options: A, C.
Rationale: Independent double-checks reduce risk for high-alert medications; verification should be separate and documented, not merely a concurrent confirmation (ISMP, 2022; WHO, 2017). Technologies like barcode administration support, but do not replace, clinical verification steps (ISMP, 2022). Pharmacy verification and e-prescribing contribute to safety but do not eliminate administration-level errors (WHO, 2017).
Item 3: Pressure injury prevention in a frail older adult with diverse skin tones
Scenario: A person aged 88 with limited mobility and darkly pigmented skin is admitted for pneumonia. They require assistance for repositioning and report decreased appetite.
Which interventions demonstrate an evidence-informed, person-centered pressure injury prevention plan?
A. Use a standardized risk assessment (e.g., Braden) on admission and with condition changes; document findings and triggers for plan updates.
B. Implement individualized repositioning with offloading and pressure-redistributing support surfaces; aim for approximately every 2 hours while balancing comfort and clinical status.
C. Rely on assessment of blanching erythema to detect early pressure injury.
D. Engage the person in shared planning, including moisture management and nutrition support, and document preferences and goals.
Correct options: A, B, D.
Rationale: Risk assessment tools guide prevention plans and reassessment intervals (NPIAP/EPUAP/PPPIA, 2019; NICE, 2014). Repositioning and offloading with appropriate surfaces are core strategies, tailored to tolerance and risk (NICE, 2014). Early injury may not present as blanching in darkly pigmented skin; relying only on blanching misses nonvisible cues (NPIAP/EPUAP/PPPIA, 2019). Person-centered care includes nutrition, moisture and skin care, and preference documentation (ANA, 2015).
Item 4: Confidentiality, multicultural care, and interdisciplinary communication
Scenario: A person aged 70 living with HIV is medically stable for discharge. Their adult family member requests details about laboratory results and medications. The team needs to coordinate home care and follow-up.
Which communication choices uphold confidentiality and support safe, coordinated care?
A. Share HIV status and detailed results with all involved family caregivers to improve support, regardless of documented permissions.
B. Apply the minimum necessary standard within the care team and obtain the person’s consent before disclosing information to family or caregivers.
C. Document the person’s privacy preferences, including who may receive information and preferred language access, in the care plan.
D. Discuss sensitive information in a public hallway to speed team coordination.
Correct options: B, C.
Rationale: Confidentiality and minimum-necessary disclosure guide information sharing; consent is obtained before sharing with family or caregivers, consistent with HIPAA Privacy Rule and ethical standards (HHS OCR, 2013; ANA, 2015). Documenting preferences and authorized contacts supports culturally responsive, person-centered communication and safer transitions (OMH, 2013; AHRQ, 2017). Conducting discussions in public spaces risks breaches of privacy (HHS OCR, 2013).
Item 5: SBAR handoff with ethical prioritization during acute deterioration
Scenario: A person aged 79 on anticoagulation has new melena, hypotension, and tachycardia. Their advance directives are noted but code status is unclear. A rapid response is called; you prepare the SBAR handoff to the hospitalist.
Which SBAR elements and content prioritize safety and respect for autonomy in this moment?
A. Situation: active GI bleeding signs; Background: anticoagulant type/dose and recent procedures; Assessment: current vitals, hemoglobin trend, mental status; Recommendation: urgent evaluation for bleeding source, transfusion protocol per policy, and clarification of code status/values with the person or surrogate.
B. Provide an unstructured narrative of the entire hospital course to ensure completeness, regardless of immediate priorities.
C. Avoid mention of code status to prevent bias; focus only on physiologic metrics.
D. Integrate the person’s known preferences and advance directives into the Recommendation, and propose next steps (e.g., consult GI, activate massive transfusion, confirm surrogate contact).
Correct options: A, D.
Rationale: SBAR promotes concise, prioritized communication that supports rapid decision-making, including key clinical risks and actionable recommendations (AHRQ, 2017; IHI, 2017). Incorporating known preferences and clarifying code status respects autonomy and guides appropriate escalation (ANA, 2015; Beauchamp & Childress, 2019). Overly long narratives can dilute critical information; excluding values may impede ethically aligned care (AHRQ, 2017).
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Discussion
These items operationalize ethical principles and patient safety practices in realistic scenarios, requiring nurses to synthesize evidence and prioritize actions. They highlight common misconceptions—such as defaulting to family interpreters for convenience, conflating pharmacy verification with clinical double-checks, relying on blanching alone in darkly pigmented skin, or omitting patient preferences from urgent SBAR communication—and provide concise rationales with references. Integrating CLAS standards and HIPAA guidance emphasizes culturally and linguistically responsive care and confidentiality. Embedding independent double-checks and structured handoffs aligns with high-reliability strategies endorsed by ISMP, WHO, AHRQ, and IHI.
For implementation, educators can use these items in simulation debriefs or summative assessments, encouraging learners to articulate their prioritization. Future work may include iterative item calibration (e.g., item difficulty, discrimination) and context-specific tailoring (e.g., local legal standards for surrogacy and consent), while maintaining alignment with foundational ethics and safety guidance.
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References
Agency for Healthcare Research and Quality. (2017). TeamSTEPPS 2.0: Strategies and tools to enhance performance and patient safety. https://www.ahrq.gov/teamstepps/index.html
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.
Appelbaum, P. S. (2007). Assessment of patients’ competence to consent to treatment. The New England Journal of Medicine, 357(18), 1834–1840. https://doi.org/10.1056/NEJMcp074045
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
Institute for Healthcare Improvement. (2017). SBAR communication technique. http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx
Institute for Safe Medication Practices. (2022). Targeted medication safety best practices for hospitals (2022–2024). https://www.ismp.org/guidelines/best-practices-hospitals
National Institute for Health and Care Excellence. (2014). Pressure ulcers: Prevention and management (CG179). https://www.nice.org.uk/guidance/cg179
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. NPIAP/EPUAP/PPPIA.
U.S. Department of Health and Human Services, Office for Civil Rights. (2013). Summary of the HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html
U.S. Department of Health and Human Services, Office of Minority Health. (2013). National standards for culturally and linguistically appropriate services (CLAS) in health and health care. https://thinkculturalhealth.hhs.gov/clas
World Health Organization. (2017). Medication without harm: Global patient safety challenge. https://www.who.int/patientsafety/medication-safety/en/
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