Legal and Ethical Issues

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Legal and EthicalIssues
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Nursing Professional Autonomy

• Autonomy occupational group has control over
  their own practice
• Autonomy conferred by
• 1) Legal regulation
• (state licensure laws)
• 2) Professional Regulation
• (standards and ethical codes)
• Many situations arent covered by specific laws.
  Professional standards and Codes of Ethics then
  serve as guidelines for conduct

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Legal Aspects

• Legal regulation of nurses thru State Nurse
  Practice Acts
• Assurance to public that nurses are prepared and
  competent
• Confer autonomy with legal limitations
• With autonomy comes accountability for decisions
  and actions
• As autonomy and responsibility increase, so does
  the level of accountability and liability
• Nurse Managers have the major responsibility for
  upholding the standards of care for the staff

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Legal Aspects

• TYPES OF LAWS
• Constitutional Law
• Statutory Law
• Enacted by government bodies
• Administrative Law
• Regulations adopted by agencies to implement
  Statutory Law
• Common Law
• Decisions of courts setting precedents

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Legal Aspects

• Two classes of wrongful acts
• Criminal Acts
• conduct that is harmful or offensive to society
• Civil Acts
• Wrongs that violate rights of individuals by
• Torts
• Breach of Contract
• Torts - Most common source of legal liability for
  nurses and Nurse Managers

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DISCUSSION

• Should health care providers be charged with
  criminal acts when physical harm or death occurs?

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Civil Legal Liability

• Judicial Risk
• Torts
• Negligence
• Malpractice
• Intentional Torts
• Strict Liability Torts
• Breach of Contracts

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Civil Legal Liability

• Judicial Risk uncontrollable variables that
  increase risk (judge / jury having a bad day
  suing another without real justification)

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Legal Liability

• Tort wrongful act committed against another
  person, organization, or property that causes
  harm
• Personal (Direct) Liability imposed on the
  person who committed the wrongful act
• Vicarious (Indirect) Liability imposed on a
  person or organization that did not commit an
  act, but is associated with the liable person

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Civil Legal Liability

• 3 Types of Torts
• Negligence (unintentional tort)
• Negligence (failure to do what a prudent person
  would do)
• Malpractice (failure to do what a prudent
  professional would do) (professional negligence)
• Intentional Tort
• Wrongful act intended to cause harm
• Strict Liability Tort
• Others endangered unintentionally
• Faulty equipment, potential dangers

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DISCUSSION

• What health care settings or positions of
  employment are more likely to encounter legal
  actions from lawsuits?

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Legal Concerns

• Nurse Managers are responsible for
• Upholding policies of their healthcare
  organization.
• Ensuring that laws of society at local,
  state, and federal levels are followed.
• (including anti-discrimination laws, OSHA,
  HIPPA, employee-related laws, etc.)
• Ensuring that management and employees follow
  policies and laws.

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Legal Concerns

• 3 Main Areas of Concern
• Personal negligence in clinical practice
• Liability for delegation and supervision
• Liability of health care organizations

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Personal Negligence in
Clinical Practice

• Ethical obligation to nonmaleficence
  (do no harm)
• Professional Negligence
• unreasonable actions
• failure to meet standards
• failure to act and prevent harm

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Personal Negligence in
Clinical Practice

• Four Elements of Professional Liability
• To establish legal liability injured party
  (plaintiff) must prove
• 1) Duty of care was owed to injured party
• 2) There was breach of that duty
• 3) The breach of duty caused injury
• 4) Plaintiff suffered actual harm or damages

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Common Examples of Negligence

• Patient falls
• Use of restraints
• Med errors
• Burns
• Equipment injuries
• Retained foreign objects
• Failure to monitor
• Failure to take action
• Failure to ensure safety

• Failure to confirm accuracy of MD orders
• Improper techniques used with treatments
• Failure to respond to a patient
• Failure to follow hospital procedure
• Failure to supervise treatment

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Liability for Delegation and
Supervision

• The nurse is responsible for tasks that she
  delegates to others.
• The nurse must monitor and supervise staff who
  are performing delegated tasks.
• If a staff member delegated to perform the task
  makes an error, the delegating nurse is also
  liable.

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CLINICAL SCENARIO

• You enter the med room and see a nurse swallow a
  pill. After she leaves the room you note that
  she had just signed out for a pain pill for her
  patient. What would you do?
• A doctor has come to the floor to make rounds on
  his patients. He has an alcohol smell on his
  breath. What would you do?

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Liability of Health Care Organizations

• Face extensive liability from several sources
• Have deep pockets
• Are almost always named as defendants in
  liability cases
• Must also have policies and follow laws regarding
  discrimination, hiring, performance appraisals,
  management of problem behavior and termination of
  employees

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Implications for the Nurse

• The best defense is a good offense.
• Be knowledgeable about
• your states Nurse Practice Act
• Scope of practice of other staff
• ANA Standards of Care
• ANA Code of Ethics and Interpretive Statements
• Hospital policies and procedures
• Maintain all current licensing, certification,
  and training requirements.
• Keep current in nursing knowledge thru continuing
  education.
• Strive to provide the highest quality of care for
  all.
• Set priorities carefully.
• Be aware of problem areas.
• Be proactive take precautions to decrease injury.

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Implications for the Nurse

• Be careful with Documentation
• Truthful / accurate / Complete
• Objective / non-judgmental
• Legible
• Utilize appropriate abbreviations
• Maintain honest, caring, respectful relationship
  with patients.
• Report unsafe, unethical practices of self and
  others thru proper channels.
• Follow proper delegation and supervision
  guidelines.
• Because all nursing staff have judicial risk,
  liability insurance is recommended for all.

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Reporting Patient Care Issues

• talk to the appropriate person in private
• clarify problem
• observe professional courtesies
• provide facts and supportive evidence
• --------------------------------------------------
  --------------------------------------------------
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• Duty to file complaints of unsafe acts
  within the facility and / or state BON
• communicate thru chain of command
• if problem urgent may need to speak with manager
  or supervisor immediately.
• may need to notify Risk Manager
• Follow policy of facility or state BON
• May remain anonymous

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Identifying Signs of Impairment

• Witnessing consumption of alcohol or other
  substances
• Changes in dress, appearance, posture, or gesture
  
• Slurred speech or abusive / incoherent language

• Reports of impairment
• Witnessed unprofessional conduct
• Lack of attention to detail
• Witnessed theft of controlled substances

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CLINICAL SCENARIO

• You enter the med room and see a nurse swallow a
  pill. After she leaves the room you note that
  she had just signed out a pain pill for her
  patient. What should you do?

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CLINICAL SCENARIO

• A doctor has come to the floor to make rounds
  on his patients and has an alcohol smell on his
  breath. What should you do?

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Impaired Nurse

• May be a candidate for
• TN Peer Assistance Program (TNPAP)
• Self-referral or board referral
• Monitoring system with guidelines
• Cease practice, agree to assistance, seek
  evaluation treatment
• Complete program with monitoring for 3-5 years
• If compliant no disciplinary action from BON

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Ethical Issues

• Ethical dilemmas deciding between right
  and wrong when all alternatives are
  equally unfavorable
• Conflicts can be between
• Professional ethics and organization ethics
• Two ethical duties to the patient
• Professional ethics and personal or religious
  ethics ?
• Duties to family / self and duties to patient ?

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CLINICAL SCENARIOS

• You are caring for a 75 year-old woman who is
  receiving palliative care for terminal cancer.
  You enter the room at 10 pm and see several
  family members around the bed and a cocker
  spaniel sitting in the patients lap. What would
  you do?

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CLINICAL SCENARIOS

• There has been a blizzard in your town. Your
  Nurse Manager calls and tells you that the staff
  is on emergency alert. She says that even though
  your arent scheduled to work that you need to
  come in now or you will lose your job. Your
  child is sick. What would you do?

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Ethical Decision Making

• Four Principles of Biomedical Ethical
  Decision Making
• 1) Autonomy (self-detemination)
• 2) Beneficience (doing good)
• 3) Nonmaleficence (doing no harm)
• 4) Justice (fairness to all equal
  treatment and distribution)

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Ethical Decision Making

• Common rules guiding ethical decision making
  include
• Fidelity
• Being loyal
• Fulfilling commitments
• Being accountable
• Veracity
• Being honest
• Not misleading
• Confidentiality
• Limits on disclosure without consent
• Privacy
• Right of physical or informational inaccessibility

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CLINICAL SCENARIOS

• You are in a hospital elevator that is packed
  with people. Two of the nurses from your floor
  are talking about a patient they have been caring
  for. What would you do?

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Ethical Decision Making

• Principles and Standards can help with ethical
  decision making.
• Nurses have the ANA Professional Codes of Ethics
  which provide framework and include Interpretive
  Statements.
• These give guidance but dont contain specifics .
• Some ethical decisions are made by the individual
  nurse or small groups.
• Other issues may be referred to an Ethics
  Committee (all hospitals should have policies for
  identifying and resolving ethical issues).

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Ethical Decision Making Model

• (using problem-solving process)
• Define the problem.
• Develop alternative courses of action.
• Evaluate each alternative.
• Select the best course of action.
• Implement the selected action.
• Monitor the results.

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CLINICAL SCENARIOS

• A patient and his family offer you a hundred
  dollar bill for giving such good care to the
  patient. What would you do?
• You discover that you are HIV . Should you tell
  your employer or coworkers?

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CLINICAL SCENARIOS

• You have given medication to the wrong patient
  and have to fill out an incident report. Should
  you tell the patient? If you think the
  medication may have caused injury to the patient
  would you make a different decision?

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CLINICAL SCENARIOS

• When you walk a patient out to be discharged, you
  notice that there are very young children in the
  car who have not car seats. What would you do?

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Ethical Dilemmas

• Common Ethical Dilemmas
• Conflict of professional ethics with
  organizational / business ethics (nursing
  shortage, cost cutting measures, refusal of
  treatments / care, floating nurses
• End of life issues (withholding treatments,
  administering unproductive life prolonging
  treatments, honoring family wishes over
  patients, right to die, euthanasia)

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CLINICAL SCENARIOS

• Your 55 year-old patient is in pain from terminal
  cancer. You know that giving him morphine will
  slow his respirations that might lead to death.
  What would you do?

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CLINICAL SCENARIOS

• An elderly woman with a severe illness stops
  breathing. She has a DNR order and a Living Will
  that specifies that she wants no medical measures
  taken to prolong her life. The womans daughter,
  who is in the room at the time, tells you that
  you have to do whatever you can to save her
  mother. What would you do? What if the woman
  said she would hire a lawyer and sue you if you
  didnt help her mother?