Ethics and Legalities in Nursing https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf

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Ethics and Legalities in Nursinghttps//www.ncsbn
.org/Professional_Boundaries_2007_Web.pdf

• Vicki Thornley, MSN, RN, CNE
• and Alicia Anger MSN,RN
• N-401
• Fall 2010

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Objectives

• Definitions as applied to ethical decisions
  nurses make during care of clients
• ANA Code of ethics
• Advance Directives - MPA
• Ethical dilemma steps

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Foundation

• Ethics philosophical ideals of right and wrong
  behavior.
• Ethics is not religion or law
• Nurses have a duty to practice ethically and
  morally
• Tells 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

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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, theyre 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

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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?

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Principles Ethical Reasoning

• Autonomy
• Beneficence
• Nonmaleficence
• Confidentiality
• Double Effect
• Fidelity
• Justice

• Paternalism
• Respect for Persons
• Sanctity of Life
• Veracity

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Autonomy

• Definition autos self, nomos rule
• Individual rights
• Privacy
• Freedom of choice
• Pt 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

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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 youre going beyond just trying to do
  good to that pt, youre trying to prevent harm

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Confidentiality

• Keep privileged information private
• Exceptions
• Protecting one persons privacy harms another or
  threatens social good (direct threat to another
  person)
• Drug abuse in employees, elder and child abuse
• HIPAA

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Double Effect

• Some actions can be morally justified even though
  consequences may be a mixture of good and evil
• Must meet 4 criteria
• The action itself is morally good or neutral
• The agent intends the good effect and not the
  evil (the evil may be foreseen but not intended)
• The good is not achieved by the evil
• There is no favorable balance of good over evil

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Fidelity

• Duty to be faithful to ones commitments
• includes implicit and explicit promises
• Make a promise, follow thru
• Implicit those promises that are implied, not
  verbally communicated
• Like when pt comes into the hospital, they expect
  to be cared for
• Explicit those that we verbally communicate
• Like if you tell them youll be back with pain
  meds, youd better come back

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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

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Paternalism

• When one individual assumes the right to make
  decisions for another
• Limits freedom of choice
• Think about parents making decisions for children
• Ex. Withholding pertinent information from a pt.
  Like elderly dx with terminal cancer, and family
  asks to not tell them that its terminal so they
  will still be motivated to fight

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Respect for Persons

• Closely tied to autonomy
• Promotes ability of individuals to make
  autonomous choices and should be treated
  accordingly
• Autonomy is preserved thru advanced directives.

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Sanctity of Life

• Life 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?

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Veracity

• The obligation to tell the truth and not to lie
  or deceive others

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Ethics and Professional Practice

• ANA Code of ethics ICN Code
• TX BON Rules Regs
• NCSBN Professional Boundaries
• Informed consent
• Durable power of attorney for healthcare guardian

• Euthanasia
• Assisted suicide
• Death
• Disasters

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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/eth
  icsstandards/codeofethicsfornurses

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ANA Code of Ethics Key Points

• Applies 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 patients
• Accountable for individual practice.
• Maintains and increases own knowledge base
• Works to improve healthcare environment for
  providers and patients

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ICN Code of Ethics

• International Council of Nurses Code of Ethics
• 4 fundamental responsibilities of Nurses
• Promote health
• Prevent illness
• Restore health
• Alleviate suffering
• http//www.icn.ch/icncode.pdf

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Nurses Rights in Ethical Situations

• Nurse has the right to refuse to participate in
  giving care to a client if they disagree with
  care on ethical grounds.
• Upheld by ANA
• Assure client is not abandoned for care
• The 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.

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Nursing Practice Regulations

• TBON Texas Board of Nursing
• Regulates nursing practice in Texas
• Creates 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/readtacext.Vi
  ewTAC?tac_view3ti22pt11

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NCSBN Professional Boundaries

• Concepts of Professional Boundaries
• Boundaries Space between nurses power and
  clients vulnerability
• Crossings 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

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NCSBN Professional Boundaries

• Concepts of Professional Boundaries
• Violations 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

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Identifying Boundary Crossings

• Excessive self-disclosure
• When the nurse discusses personal feelings or
  aspects of their personal life in front of the pt
• Secretive behavior
• When 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 client
• Selective communication
• When the nurse fails to explain actions or
  actions of care

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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 doesnt recognize sexual feelings towards
  the client

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Nurses Challenge

• Be aware
• Be cognizant of feelings and behaviors
• Be observant of the behavior of other
  professionals
• Always act in the best interest of the client
• https//www.ncsbn.org/Professional_Boundaries_2007
  _Web.pdf

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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 cant
  go in and explain the procedure again, if you
  contradict what the doc told the pt, youre in
  big trouble! Dont do it!

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Capacity to Form Consent

• Decision-making capacity (not competency)
  determined by
• Appreciation of right to make the choice
• Understanding of risks/benefits of procedure
• Understanding of risks/benefits of opting out of
  procedure
• Ability to communicate decision
• Communication may not always be verbal, can be
  written or whatever
• Needs to have interpreter avl! Cant just use the
  family or whatever
• Use layman jargon. Normal words Dont say layman
  jargon.

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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.

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Other Contingencies

• Directives unavailable / never done
• Autonomy versus best interest of clients
• Substituted judgment
• Legal standard that presumes the surrogate is
  capable of making decisions for that pt
• Dementia clients
• Dementia diagnosis doesnt 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.

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Withholding/Withdrawing Care

• Can withhold inhumane treatment if it is
  virtually futile in extending life usually
  DNR
• Allowing to die vs making die

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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

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Assisted Suicide

• Patient actively seeks physician/nurse to help
  them commit suicide
• Criminal offense in all states but Oregon,
  Washington, and Montana
• Usually pt is given prescriptions in amts that
  are legal and the pt decides if they want to use
  it.

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Defining Death

• Uniform 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)

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Ethical Dilemmas

• the action or situation involves actual or
  potential harm to someone or some thing
• a possibility of a violation of what we generally
  consider right or good
• is this issue about more than what is legal or
  what is most efficient?

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How to Process an Ethical Dilemma

• Determine whether or not a dilemma exists
• Gather all relevant information
• Reflect on your values on the issues
• Verbalize problem
• Consider all possible courses of action
  including referral to ethics committee
• Negotiate outcome
• Evaluate action, not the outcome.

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Conclusion

• Know yourself and your values
• Protect your patient by intervening if you
  identify an ethical question
• Know your facility policy for access to the
  ethics committee
• Know your responsibilities with regard to
  informed consent
• Respect the patients advance directives

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Excerpts ANA Code of Ethics

• The 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.

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Excerpts (contd)

• The nurses 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.

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Excerpts (contd)

• 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.

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Excerpts (contd)

• 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.

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Excerpts (contd)

• 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

Alicia Anger, MSN, RN N-401 Fall 2010
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Learning Outcomes

• Describe sources of law that affect nursing
  practice
• Professional negligence
• Avoiding Malpractice claims
• Causes for suspension/revocation of license
• Legal responsibilities of Nurse Leaders

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Distinction between Law and Ethics
Concepts Law Ethics
Source External Internal
Concerns Conduct and Actions Motive, attitude, culture
Interests Society Individual
Enforcements Courts, BON Ethics Committee and professional organizations
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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)

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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

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Professional Negligence

• Five components necessary for professional
  negligence to occur
• Standard of care
• Failure to meet standard
• Foreseeability of harm
• Correlation b/t care and harm must be proven
• Actual patient injury must occur

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Professional Negligence

• Reducing the Risk
• Know the law
• Document everything
• Refrain from negative comments
• Question authority
• Stay educated
• http//www.nurseweek.com/features/00-05/malpract.h
  tml

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Professional Negligence

• Reducing the Risk cont.
• Manage risks
• Dont hurry through discharge
• Be discreet
• Use restraints wisely
• Be kind
• http//www.nurseweek.com/features/00-05/malpract.h
  tml

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Liability

• Liable to be legally responsible by law
• Personal liability every person is liable for
  his/her own conduct
• Joint liability nurse, physician, and employing
  organization are liable
• Respondeat superior liability the master is
  responsible for the acts of his servants

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Claims Against Nurses

• Inadequate charting.
• Inadequate communication w/ HCP or supervisors
  about changes in pt condition
• Leaving potentially harmful items within patient
  reach

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Claims Against Nurses

• Unattended pt falls
• Inaccurate counting of operative instruments
  sponges
• Misidentifying patients for medications,
  surgeries tests

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Incident Reports

• Incident reports cant 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.
• Dont 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.
• Dont tell the pt or family that youre filling
  one out! Youre not keeping them from any
  information about the incident, youre just not
  telling them about the form
• Dont document on pts 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. Its just the hospitals
  policy to keep tabs on all the shit that goes
  wrong inside its walls

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Incident Reports

• Unusual / unexpected incidents
• Do
• Document incident information, treatment follow
  up on chart
• Notify Nsg Management Risk Management
• DO NOT
• Leave copy on chart
• Discuss with pt / family
• Document 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, blah blah blah.
  Being truthful reduces risks of being charged
  with this
• Invasion of privacy

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Types of Consent

• Informed consent
• Implied consent
• Pt unable to consent
• Treatment is in patients best interest
• Express consent
• Witness pt signature
• Assure pt received information

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Informed Consent

• Language pt understands
• Patient competency
• Requires full disclosure (procedure process,
  risks and benefits)

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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 Suspension

• Professional negligence
• Practicing nursing w/o a license
• Obtain license by fraud
• Felony convictions

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Causes of License Suspension

• Not reporting substandard medical or nursing care
• Providing patient care under the influence of
  drugs/alcohol
• Giving 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

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Malpractice for Nurse Leader

• Assignments
• Pt assignments
• Delegation
• Supervision
• Orientation Education
• Evaluation
• Staffing

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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)

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Whistleblower Act

• To 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 Act

• Generally, 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

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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

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Joint Commission

• Independent 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/

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Joint Commission

• National Patient Safety Goals
• Improve accuracy of patient identification
• Improve the effectiveness of communication among
  caregivers
• Improve the safety of using medications
• Reduce the risk of healthcare associated
  infections
• http//www.jointcommission.org/AboutUs/

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Joint Commission

• National 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 ulcers
• The organization identifies safety risks inherent
  in its patient population
• Universal protocol
• http//www.jointcommission.org/AboutUs/

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Centers for Medicare Medicaid

• The Centers for Medicare Medicaid Services
  (CMS) is a branch of the U.S. Department of
  Health and Human Services. CMS is the federal
  agency that administers the Medicare program and
  monitors the Medicaid programs offered by each
  state.
• http//www.cms.gov/

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Centers for Medicare Medicaid

• Works closely with TJC to maintain patient safety
• Reimburses according to meeting standards of care
• Healthcare-associated infections
• Hospital-acquired conditions
• http//www.cms.gov/

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References

• Potter, P. A., Perry, A.G. (2009) Fundamentals
  of Nursing (7th ed.). Canada Mosby.
• Smeltzer, S. C., Bare, B. G. (2008). Brunner
  Suddarth's textbook of medical-surgical nursing
  (11th ed.). Philadelphia, PA Lippincott
• Markkula Center for Applied Bioethics.
  http//www.scu.edu/ethics
• Texas Engineering Extension Service (TEEX),
  Center for Disease Control and Prevention (CDC),
  The Texas AM University System (TAMUS),
  National Emergency Response and Rescue Training
  Center (NERRTC). (2003). Integrated Health and
  Medical WMD Training Program. (Original work
  published 2001, Texas Engineering Extension
  Service (TEEX), College Station, TX.
• Marquis, B. Huston,C. (2009) Leadership roles
  and management functions in nursing (6th ed).
  Philadelphia, PA LIppincott