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Ethics and Legalities in
Nursing
By:- firoz qureshiDept. psychiatric nursig
ObjectivesDefinitions as applied to ethical decisions
nurses make during care of clientsANA Code of ethicsAdvance Directives - MPAEthical dilemma steps
FoundationEthics – philosophical ideals of right and wrong
behavior.Ethics is not religion or lawNurses have a duty to practice ethically and
morallyTells us how human beings should behave, not
necessarily what they do. Not a religion, not law, but both of these can be the basis of ethical decisions that you make.
The word duty is a legal term…
Ethical Issues Moral uncertainty/conflict
When the nurse is unsure which moral principle to apply, or even what the problem is. Common with new nurses, they’re not sure what they are supposed to be doing
Moral distress When the individual knows the right thing to do but
organizational constraints keep them from doing it Moral outrage
An individual witnesses an immoral act by another but feels powerless to stop it
Moral/ethical dilemma Occurs when two or more clear principles apply but they
support inconsistent courses of action Self-awareness
Not an ethical issue, but is absolutely vital in ethical decision making
Ethical Frameworks Utilitarian – most good, least harm
Most common approach, “First do no harm” is related to this. Attempts to produce the greatest good with the least harm.
Rights based– best protects the rights and respects the moral rights of those affected Begins with idea of human dignity and freedom of choice. The pt
has the right to make the decision. Duty based- duty to do or to refrain from doing something
Decisions are made because there is duty! Common good – best for community/society
Decisions should be made on what is good for the community as a whole, not necessarily for the individual. Where many of our nations laws are base
Virtue – actions consistent with certain ideal virtues Decisions should be directed at maintaining virtues (honesty,
courage, compassion, etc.). A person using this approach may ask themselves, “If I carry out these actions, what kind of person will I be?”
Principles Ethical ReasoningAutonomyBeneficenceNonmaleficenceConfidentialityDouble EffectFidelityJustice
PaternalismRespect for PersonsSanctity of LifeVeracity
AutonomyDefinition: “autos” = self, “nomos” = rule
Individual rightsPrivacyFreedom of choicePt has the right to make decisions for
themselves. May see this come up with consent for treatment issues, informed consent. Pt has right to know procedure, complications, other options, that they can opt to not have the procedure/treatment. Framework is rights based
Beneficence & Nonmaleficence Duty to do good
goodness, kindness, charity
Includes nonmaleficence
Centerpiece for caring
Duty: NOT TO CAUSE harm
Duty: PREVENT harm Duty: REMOVE harm More binding than
beneficence Because you’re going
beyond just trying to do good to that pt, you’re trying to prevent harm
ConfidentialityKeep privileged information privateExceptions
Protecting one person’s privacy harms another or threatens social good (direct threat to another person)
Drug abuse in employees, elder and child abuseHIPAA
Double EffectSome actions can be morally justified even though
consequences may be a mixture of good and evilMust meet 4 criteria:
The action itself is morally good or neutralThe agent intends the good effect and not the evil
(the evil may be foreseen but not intended)The good is not achieved by the evilThere is no favorable balance of good over evil
FidelityDuty to be faithful to one’s commitments
includes implicit and explicit promisesMake a promise, follow thru
Implicit – those promises that are implied, not verbally communicatedLike when pt comes into the hospital, they expect
to be cared forExplicit – those that we verbally communicate
Like if you tell them you’ll be back with pain meds, you’d better come back
Justice Seeks
fairness More
specifically, distributive justice refers to distribution of benefits and burdens
Distributive Justice Concepts Equally disbursed
according to Need Effort Societal
contribution Merit Legal entitlement
PaternalismWhen one individual assumes the right to make
decisions for anotherLimits freedom of choiceThink about parents making decisions for childrenEx. Withholding pertinent information from a pt.
Like elderly dx with terminal cancer, and family asks to not tell them that it’s terminal so they will still be motivated to fight
Respect for PersonsClosely tied to autonomyPromotes ability of individuals to make
autonomous choices and should be treated accordingly
Autonomy is preserved thru advanced directives.
Sanctity of LifeLife is the highest good
All forms of life, including mere biologic existence, should take precedence over external criteria for judging quality of life
If life is the highest good, is it ethical to keep a brain dead person alive?
VeracityThe obligation to tell the truth and not to lie or
deceive others
Ethics and Professional PracticeANA Code of ethics &
ICN CodeTX BON Rules & RegsNCSBN Professional
BoundariesInformed consentDurable power of
attorney for healthcare guardian
EuthanasiaAssisted suicideDeathDisasters
American Nurses Association(ANA) Code of Ethics
Applies to all nurses in all healthcare settings
Ethical principles agreed upon by members of the nursing profession
Sets standards of conduct and behaviors for nurses
http://www.nursingworld.org/mainmenucategories/ethicsstandards/codeofethicsfornurses
ANA Code of Ethics – Key PointsApplies in course of professional practice:
Primary commitment is to patient (individual, family or community)
Demonstrates compassion and respect for all patients regardless of patient status
Promotes the health and welfare of patientsAccountable for individual practice. Maintains and increases own knowledge baseWorks to improve healthcare environment for
providers and patients
ICN Code of EthicsInternational Council of Nurses Code of
Ethics4 fundamental responsibilities of Nurses
Promote healthPrevent illnessRestore healthAlleviate suffering
http://www.icn.ch/icncode.pdf
Nurses Rights in Ethical SituationsNurse has the right to refuse to
participate in giving care to a client if they disagree with care on ethical grounds.Upheld by ANAAssure client is not abandoned for careThe Joint Commission (TJC) requires
employers to establish policies and mechanisms to address staff requests not to participate in aspects of care that conflict with cultural values or religious beliefs.
Nursing Practice RegulationsTBON – Texas Board of Nursing
Regulates nursing practice in TexasCreates Rules and Regulations to administer the
Nurse Practice Act (NPA)Describes rules of conduct for nurses
Rule 213.27 – Good Professional Character Rule 217.11 – Standards of Practice Rule 217.12 – Unprofessional Conduct
http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=3&ti=22&pt=11
NCSBN Professional BoundariesConcepts of Professional BoundariesBoundaries: Space between nurse’s power
and client’s vulnerabilityCrossings: Brief excursions across
boundaries that may be inadvertent, thoughtless, or even purposeful if done to meet a specific therapeutic need
https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf
NCSBN Professional BoundariesConcepts of Professional BoundariesViolations: results when there is confusion
between the needs of the nurse and those of the client.
Sexual misconduct: extreme form of violation that is seductive, sexually demeaning, harassing or interpreted as sexual by the client.
https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf
Identifying Boundary CrossingsExcessive self-disclosure
When the nurse discusses personal feelings or aspects of their personal life in front of the pt
Secretive behaviorWhen the nurse keeps secrets with the client or
when the nurse becomes guarded when someone questions their interactions
“super nurse”When the nurse believes only he or she can meet the
needs of the clientSelective communication
When the nurse fails to explain actions or actions of care
Identifying Boundary Crossings Singled out client treatment/client attention
to the nurse Nurse spends inappropriate amts of time with
the client, client may give gifts to the nurse Flirtations
Never, ever, appropriate, or ok, ever, ever… You and me against the world behavior
Nurse views client in a protective manner Failure to protect the client
Nurse doesn’t’ recognize sexual feelings towards the client
Nurse’s ChallengeBe awareBe cognizant of feelings and behaviorsBe observant of the behavior of other
professionalsAlways act in the best interest of the client
https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf
Informed Consent Core underlying value is patient autonomy Physician / practitioner obtains consent Nurses role: witness / monitor Emergency consent is presumed when patient
unable to provide Informed consent is a process that people go
thru, not just a paper. Nurses role is to make sure pt understands
everything and that the person that signs is the person who needs to be signing! The nurse can’t go in and explain the procedure again, if you contradict what the doc told the pt, you’re in big trouble! Don’t do it!
Capacity to Form ConsentDecision-making capacity (not competency)
determined by:Appreciation of right to make the choiceUnderstanding of risks/benefits of procedureUnderstanding of risks/benefits of opting out
of procedureAbility to communicate decision
Communication may not always be verbal, can be written or whatever
Needs to have interpreter avl! Can’t just use the family or whatever
Use layman jargon. Normal words… Don’t say layman jargon.
Advance Directives
Include Directive to Physician and Family or Surrogate
Most common. Allows pt to document wishes for tx or withdrawal, also commonly known as “Living Will”
Medical Power of Attorney Allows the pt to designate another person as their decision maker
Out of Hospital Do-Not-Resuscitate Order Allows competent adults to refuse life sustaining procedures when out
of the hospital setting. Can include not wanting to be taken to ER, let me sit here and die…
Declaration of Mental Health Treatment Allows a court to determine incapacity and allows the pt to refuse
electro convulsive therapy (ECT) and psychoactive drugs Sometime generically called “Living Will” Not same as DNR (do not resuscitate)
These are written during hospitalization after the doc and the pt (or pt surrogate) decide to withdrawal life sustaining treatments.
Advanced Directives are documents that state in writing the pts wishes for healthcare interventions if they should become incapacitated.
Other Contingencies…Directives unavailable / never done
Autonomy versus “best interest” of clientsSubstituted judgment
Legal standard that presumes the surrogate is capable of making decisions for that pt
Dementia clients Dementia diagnosis doesn’t necessarily mean the pt is
incapable of making their own decisions. Esp in the first few stages of dementia. Pt is very alert and very aware and very much can make that decision for themselves.
Withholding/Withdrawing CareCan withhold “inhumane” treatment if it is
“virtually futile” in extending life – usually DNRAllowing to die vs making die
Euthanasia Definition – intentional termination of life (at the request
of that person who wishes to die)Active vs. Passive
Generally illegal May be legal under certain circumstances Active – involves purposefully causing the persons death
(doc or nurse). Dr. Kevorkian. Usually involved with law problems
Passive – involves hastening of death by altering some form of support, taking a pt off a vent, generally accepted by medical community
Terminal sedation Doctrine of Double Effect (the whole intent of the act, thing) Do a thing with one intent, but causes something else to
happen – morphine OD Procedure used in dying pts to relieve suffering. Pts who are
in extreme pain may chose terminal sedation
Assisted SuicidePatient actively seeks physician/nurse to “help”
them commit suicideCriminal offense in all states but Oregon,
Washington, and MontanaUsually pt is given prescriptions in amts that are
legal and the pt decides if they want to use it.
Defining DeathUniform Determination of Death Act – patient
is dead if any one of the following conditions are met:Cardiopulmonary death Neurological death
Whole brain death – Flat EEG Not PVS – (persistent vegetative state)
Ethical Dilemmasthe action or situation involves actual or
potential harm to someone or some thinga possibility of a violation of what we generally
consider right or goodis this issue about more than what is legal or
what is most efficient?
How to Process an Ethical Dilemma1. Determine whether or not a dilemma
exists2. Gather all relevant information3. Reflect on your values on the issues4. Verbalize problem5. Consider all possible courses of action
– including referral to ethics committee
6. Negotiate outcome 7. Evaluate action, not the outcome.
ConclusionKnow yourself and your valuesProtect your patient by intervening if you
identify an ethical questionKnow your facility policy for access to the
ethics committeeKnow your responsibilities with regard to
informed consent Respect the patient’s advance directives
Excerpts: ANA Code of EthicsThe nurse, in all professional
relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
Excerpts (cont’d)The nurse’s primary commitment is to
the patient, whether an individual, family, group, or community.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
Excerpts (cont’d)The nurse is responsible and
accountable for individual nursing practice; and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care.
Excerpts (cont’d)The nurse owes the same duties to self
as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
Excerpts (cont’d)The nurse participates in establishing,
maintaining, and improving health care environments and conditions of employment conductive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
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Nursing Legalities
Concepts Law Ethics
Source External Internal
Concerns Conduct and Actions
Motive, attitude, culture
Interests Society Individual
Enforcements Courts, BON Ethics Committee and professional organizations
Distinction between Law and Ethics
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What is law? Law
Rules of conduct Authored & enforced by formal authorities Hold people Accountable for compliance
Purpose of Nursing Law Protect – patient and nurse Scope of practice (define it)
Sources of Law Constitution: establishes a basis for a
governing system (highest law that gives authority to the other branches)
Statutes: laws that govern Administrative agencies: given authority
to create rules and regulations to enforce statutes (like texas board of nursing)
Court decisions: interpret statutes and determine consequences
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Types of Court Cases & Laws Criminal law: crimes committed against an individual or
society, innocent until proven guilty beyond a reasonable doubt. Consequences range from fine to jail to death penalty
Civil law: one individual sues another for money b/c of a perceived loss. Guilty verdict is based on the belief that the accused is more likely than not to have caused the injuries. Consequence is usually $$
Administrative law: individual is sued by a state/federal agency responsible for enforcing statutes. Based on a clear and convincing standard.
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Professional Negligence
Negligence: the omission to do something that a
reasonable and prudent person in a reasonable situation
would or would not do
Prudent: the average judgment, foresight, intelligence and
skill expected of a person of similar training or experience
Malpractice: failure of a person with professional
training to act in a reasonable and prudent manner
50
Professional NegligenceFive components necessary for professional
negligence to occur:
1. Standard of care
2. Failure to meet standard
3. Foreseeability of harm
4. Correlation b/t care and harm must be proven
5. Actual patient injury must occur
Professional NegligenceReducing the Risk:Know the lawDocument everythingRefrain from negative commentsQuestion authorityStay educated
http://www.nurseweek.com/features/00-05/malpract.html
Professional NegligenceReducing the Risk cont.:Manage risksDon’t hurry through dischargeBe discreetUse restraints wiselyBe kind
http://www.nurseweek.com/features/00-05/malpract.html
LiabilityLiable: to be legally responsible by lawPersonal liability: every person is liable for
his/her own conductJoint liability: nurse, physician, and
employing organization are liableRespondeat superior liability: “the master
is responsible for the acts of his servants”
53
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Claims Against NursesInadequate charting.
Inadequate communication with health care provider or supervisors about changes in patient condition
Leaving potentially harmful items within patient reach
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Claims Against NursesUnattended pt falls
Inaccurate counting of operative instruments & sponges
Misidentifying patients for medications, surgeries & tests
Incident Reports Incident reports can’t be used in court, unless they
(lawyers and what not) find out that it exists. They are intended for internal shit only, within the hospital, monitoring trends, prevention of future occurrences, etc.
Don’t put them in the chart! You can document the fall, what you did to make it better, but not that you filled out the actual incident report form.
Don’t tell the pt or family that you’re filling one out! You’re not keeping them from any information about the incident, you’re just not telling them about the form…
Don’t document on pt’s chart that you filled one out! Notify nurse management teams and what not when you
fill it out. Remember, there is no law about having to fill out an
incident report. It’s just the hospitals policy to keep tabs on all the shit that goes wrong inside it’s walls
57
Incident ReportsUnusual / unexpected incidents Do
Document incident information, treatment & follow up on chart
Notify Nsg Management & Risk Management DO NOTLeave copy on chartDiscuss with pt / familyDocument form completion in chart
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Intentional Torts Assault & Battery
Assault is the behavior that makes a person fearful of harm
Battery is an intentional physical contact with a person that causes injury
False Imprisonment Any unlawful confinement within fixed boundaries,
can be physical, emotional, or chemical Defamation of character (slander)
Communicating to a 3rd party information that can hurt character, self esteem. Being truthful reduces risks of being charged with this.
Invasion of privacy
59
Types of ConsentInformed consent
Implied consentPt unable to consent Treatment is in patients best interest
Express consentWitness pt signature Assure pt received information
60
Informed Consent
Language pt understands
Patient competency
Requires full disclosure (procedure process,
risks and benefits)
61
Medical Records
Although the patient owns the information in
the medical record, the actual record belongs to
the facility that originally made record & is
storing it
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Causes of License SuspensionProfessional negligence
Practicing nursing w/o a license
Obtain license by fraud
Felony convictions
Causes of License SuspensionNot reporting substandard medical or nursing
careProviding patient care under the influence of
drugs/alcoholGiving narcotics w/o order Falsely portraying self to public or any HCP as a
nurse
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Legal Responsibilities of a Nurse Leader
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Legal Responsibilities of the Nurse Leader Reporting dangerous understaffing
Texas passed law saying you have to have rules and policies set up and in place in case staffing issues arise
Ensuring staff credentials and qualifications Quality Control of nursing practice Equipment operation by staff Reporting substandard care Responsibility to be fair and nondiscriminatory
Malpractice for Nurse Leader Assignments
Pt assignments
Delegation
Supervision
Orientation & Education
Evaluation
Staffing66
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The Patient Self-Determination Act
Requires health care organizations that receive
federal funding to provide education for staff and
patients on issues concerning treatment and end-of-life
issues. (They have to ask about Advanced Directives
and what not on admission and inform them about it)
Whistleblower ActTo prevent employers from taking retaliatory
action against nurses such as suspension, demotion, harassment or discharge for reporting improper patient care or business practices
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Good Samaritan ActGenerally, a nurse is not liable for injury that
occurs as a result of emergency treatment, provided that:
Care is provided at the scene of emergency
The care is not grossly negligent
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Health Insurance Portability and Accountability Act
Protects the privacy of health information
Administrative Simplification plan All related to electronic medical records,
simplifying exchange of info and what not, by 2014 all hospitals have to have this
Privacy Rules
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Diverse Workforce Title VII (Civil Rights Act-1964): Protects
against discrimination based on race, color, creed, national origin, religion or sex
Age Discrimination in Employment: no discrimination over age 40
American with Disabilities Act: no discrimination against physical or mental impairment regarding hiring
Diverse Workforce Equal Pay Act: no discrimination against
women
Occupational Safety & Health Act: safe and healthy work environment
Family & Medical Leave Act: provides job security for taking leave of absence
Joint CommissionIndependent not for profit organization that
accredits and certifies healthcare organizations
Purpose: continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value
http://www.jointcommission.org/AboutUs/
Joint CommissionNational Patient Safety GoalsImprove accuracy of patient identificationImprove the effectiveness of communication
among caregiversImprove the safety of using medicationsReduce the risk of healthcare associated
infections
http://www.jointcommission.org/AboutUs/
Joint CommissionNational Patient Safety Goals cont.:
Accurately and completely reconcile medications across the continuum of care
Reduce the risk of patient harm resulting from falls
Prevent healthcare associated pressure ulcersThe organization identifies safety risks inherent in
its patient populationUniversal protocol
Thank you
