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  1. Ethical and Legal Aspects of Nursing

  2. Ethical and Legal Aspects of NursingObjectives • Define the following terms: value, value system, ethics, ethical dilemma, ethical distress, ethical decision making • Understand the meaning of the following terms: bioethics, clinical ethics, nursing ethics • Be able to discern personal values and how they might influence decision making as a nurse

  3. Ethical and Legal Aspects of Nursing Objectives • Define the sources and types of laws • Define standards of care and how they are established • Define a nurse’s fiduciary duty to a patient • Understand: Advance Directives, restraint guidelines, public health laws, determination of death, Good Samaritan laws, HIPPA regulations • Define intentional and unintentional torts • Understand legal responsibilities of student nurses

  4. Ethical and Legal Aspects - Objectives • State the purposes of the medical record • State the guidelines for quality documentation • List some types of charting • State the requirements for giving report • List some common charting mistakes leading to medical malpractice

  5. Definitions • Value: a belief about the worth of something, about what matters, a guide for behavior • Value system: an organization or ranking of values • Ethics: systematic inquiry into principles of right and wrong conduct, virtue and vices, good and evil. Ethics is different from religion, law, custom and institutional practices

  6. Definitions • Ethical dilemma: Occurs when conflicting courses of action are present “Often thought to apply to only end-of-life decisions, ignoring such issues as an honest day’s work, how respectful we are to others, how truthful, how compassionate” • Ethical distress: When the nurse knows the right thing to do, but the situation makes doing that difficult

  7. Class Discussion - Values • Please write down 3 qualities that you particularly admire/want to see in other people • Write down 3 qualities that you particularly like about yourself • Write down 3 qualities that you think are essential in a nurse

  8. How do personal values influence ethical choices in nursing?

  9. Types of Ethics • Bioethics: Concerns the life sciences Issues regarding: Research conduct, environmental ethics, sustainable healthcare • Clinical ethics: Concerns issues at the bedside Issues regarding: consent or refusal of treatment, assisted suicide, requests for futile treatment • Nursing ethics: concerns clinical nursing issues Issues regarding: allocation of care and resources, confidentiality, unethical or incompetent conduct of colleagues

  10. Theories of Ethics • These are action-guiding theories • These are systems developed to answer the question “What do I do?” • Utilitarian: the rightness or wrongness of an action depends on the consequences of that action • Deontologic: an action is right or wrong independent of its consequences

  11. Principle-Based Approach to Ethics • States that ethical decisions should be based on 5 principles: • Autonomy - Right of individuals for self-determination • Nonmaleficence - Avoid causing harm • Beneficence - Provide benefit; do good • Justice - act fairly to all • Fidelity - act honestly; keep promises

  12. American Asso. of Colleges of Nursing • Altruism: understanding the perspective of others Advocating for patients Taking risks on behalf of patients and colleagues Mentors others • Human dignity: Providing culturally sensitive care Providing privacy Confidentiality Sensitivity

  13. American Asso. Of Colleges of Nursing • Integrity: honesty in providing information to patients and families Honest documentation Seeking to remedy errors Accountability • Autonomy: patient’s right to determine the course of treatment • Social justice: fairness, equal treatment for all

  14. Ethical Agency • The ability to behave in an ethical way and do the right thing because it is the right thing to do • Requires: • Ethical sensibility • Ethical responsiveness • Ethical reasoning and discernment • Ethical accountability • Ethical character • Ethical valuing • Transformative ethical leadership

  15. Code of Ethics for Nurses Purpose: • It is a succinct statement of the ethical obligations and duties of every nurse • It is the profession’s nonnegotiable ethical standard • It is an expression of nursing’s own understanding of its commitment to society

  16. Ethical decision-making • Use nursing process: • Assessment: gather all available data • Diagnosis: name the problem/ethical issue • Planning: decide how to deal with this issue • Implementation • Evaluation

  17. Common Ethical Issues for Nurses • Balance between benefits and harms • Disclosure, informed consent, and shared decision making • Norms of family life • Relationship between clinicians and patients

  18. Ethical Issues for Nurses • Cost-effectiveness and allocation • Professional integrity of clinicians • Issues of cultural and/or religious variations • Considerations of power • Unprofessional conduct

  19. Ethics Committees • Functions: • Education • Policy making • Case review • Consultation

  20. Advocacy in Nursing Practice • Primary commitment to the patient • Priority to good of individual patient rather than society in general • Evaluation of competing claims of patient’s autonomy and patient well-being

  21. Legal Issues

  22. Law • Definition: • Standard or rule of conduct established • and enforced by government • Designed to protect the rights of the public

  23. Definitions • Litigation: the process of bringing and trying a lawsuit • Plaintiff: person bringing the lawsuit (the accuser) • Defendant: the person accused • Trial court: first level court • Appellate court: appeals court (where the case goes if the verdict in the trial court is appealed)

  24. Types of laws • Public law—government is directly involved • Regulates relationships between individuals and government • Private law—civil law • Regulates relationships among people • Criminal law—concerns state and federal criminal statutes • Defines criminal actions, e.g., murder, theft

  25. Sources of Law • Statutory law - created by elected bodies: State legislatures and congress Ex.: The Bill of Rights; Nurse Practice Acts in all 50 states which define the legal boundaries of nursing practice • Regulatory or administrative law - Created by state Boards of Nursing when they pass rules and regulations Ex.: Duty to report incompetent or unethical nursing conduct

  26. Sources of Law • Common law - Created by judicial decisions made in courts when individual cases are decided Ex.: Informed Consent, Patients right to refuse treatment, Roe vs. Wade

  27. Types of Statutory Law • Criminal law - designed to prevent harm to society and provide punishment (public law) a. Felony: more serious crime, punishable by imprisonment for greater than 1 year, or death b. Misdemeanor: less serious crime, punishable by imprisonment for less than 1 year • Civil Law - designed to protect the right of individuals and encourage fair and equitable treatment among people. (private law) Violations of civil law are damages to an individual or property. Damages are usually payment of money. • Under many state and federal laws sanctions may include civil and criminal penalties • In all cases, the defendant is innocent until proven guilty.

  28. Standards of Care • Def: the legal guidelines for nursing practice. Usually involves “What a reasonable and prudent nurse would do in the same or similar circumstances”. • A breach of nursing standards must be proven in the tort of nursing negligence or malpractice.

  29. Standards of Care are defined by: • Nurse Practice Acts passed by State legislatures a. Define scope of practice b. Provide guidelines for delegation c. Define educational requirements • State Boards of Nursing a. May define nursing practice more specifically (ex: Rules regarding IV therapy) • Professional Boards (ANA) • Specialty Nursing Organizations (IV Therapy Nurses Org.; Nurse Midwifery Org.)

  30. Standards of Care are defined by: • JCAHO requirements • Hospital Nursing Policy and Procedures

  31. Standards of Practice • All nurses are responsible for knowing provisions of the State Practice Act and the regulatory law passed by the State Board of Nursing • All nurses are required to know the policies and procedures of the hospital in which they work. The same standards must apply to all nurses and they must not conflict with other guidelines or laws. • JCAHO requires hospitals have written policy and procedure manuals which describe specifically how procedures should be done. They must be easily accessible. (or on-line)

  32. Standards of Care • In legal proceedings the legal nurse expert testifies about the standard of care which may or may not have been violated.

  33. Nurse’s Fiduciary Duty to Client • Must provide knowledgeable and safe care • Must behave honestly and truthfully with regard to the client • Must be faithful to provide care in the best interest of the client

  34. Legal Issues for Nurses • Advance Directives: Living Will and Durable Power of Attorney a. DNR issues b. Right to refuse treatment • Restraint laws Nurse must be aware of hospital policy and procedure regarding restraints and follow it • Public Health Laws: Reporting suspected neglect/abuse, communicable disease

  35. Legal Issues for Nurses • Determination of Death Law • HIPPA policies - Health Insurance Portability and Accountability Act a. Protects patient confidentiality b. Now includes monetary damages for violations

  36. Civil and Common Law Issues in Nursing Practice • Tort: A civil wrong made against a person or property • Unintentional tort: negligence or malpractice - conduct which falls below the standard of care. The following must be proven: a. The nurse owed a DUTY to the patient. b. There was a BREACH OF DUTY because the nurse did not carry it out. (Testimony from: Expert witnesses, standards of Care, Hospital Policy and Procedure) c. The patient suffered HARM. d. The nurse’s failure to carry out the duty was CAUSATION of the harm

  37. Torts: Unintentional - Nursing Malpractice or Negligence So there are 4 critical elements that must be proven in a malpractice case: DUTY BREACH OF DUTY HARM CAUSATION OF HARM

  38. Torts: Intentional • Assault and Battery: Assault is the threat to bring about harm; Battery is any intentional touching without consent. Ex: performing a procedure that the patient has not consented to. • Invasion of Privacy: Ex: release of medical info to unauthorized person, confidentiality of medical record • False imprisonment: Ex: Patient’s right to leave AMA • Libel/Slander: False statements which damage a person’s reputation (libel is written; slander is oral) • Fraud: intentionally misleading another person with the intention of causing legal injury or deprive the person of a right

  39. Other Legal Issues • General Consent: Signed and implied when the patient is admitted to the hospital - vital signs, assessments, all MD orders • Informed Consent: required for all routine treatments and hazardous procedures (Ex: transfusions, chest tubes, central lines, surgical procedures) a. MD’s responsibility to explain the procedure and the risks b. Nurses witness patient signature that: the person willingly gave consent, signature is authentic, client appears competent.

  40. Informed Consent

  41. Other legal issues • Informed Consent: c. Patient must be capable of giving consent (sedation, language barriers) d. Key components: completeness, comprehension, voluntariness, competence

  42. Legal issues - Student Nurses • Are liable if their actions cause harm to a patient • Liability is shared by the instructor, hospital and educational institution - “Respondent Superior” meaning the hospital will be held liable for employee/student actions • Student nurses are expected to perform as a professional LVN would - they are not held to a lower standard of care • The LVN or RN assigned to the patient is still responsible for the patient.

  43. Legal issues - Student Nurses • To minimize student liability the student should: a. Be prepared to carry out the necessary care for assigned patients. b. Ask for additional help or supervision in situations for which they feel inadequately prepared. c. Comply with the policies of the agency in which they obtain their experience. d. Comply with the policies and definitions of responsibility supplied by the school of nursing

  44. Other issues • Short staffing • Abandonment • Floating • MD orders: a. Must be carried out specifically, unless the nurse believes them to be erroneous b. Must be questioned if erroneous or ambiguous

  45. MD Orders - Tips • Question any order the client questions • Question any order if the patient’s condition has changes • Question (read back) and record verbal orders to avoid miscommunication • Question any order which illegible, unclear or incomplete

  46. Tips to avoid malpractice • Follow and keep abreast of current standards of care (Continuing Education) • Give competent care • Develop a caring rapport with the client and family while observing professional boundaries • Communicate with other health care providers • Document assessments, interventions and evaluations fully (best defense) • Follow the policy and procedure of the institution

  47. Tips to avoid malpractice • Be aware of potential sources of injury (falls, med errors, name errors) • Communicate with the patient and explain procedures • Report and document changes in patient condition • Timely, truthful, legible and thorough documentation • Delegate appropriately • Accept assignments for which you are qualified

  48. Documentation