Transcript Legal Aspects of Nursing - City College of San Francisco

Ethical and Legal Aspects of Nursing
Ethical and Legal Aspects of Nursing
Objectives
 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
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
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
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
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
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
 How do personal values influence ethical
choices in nursing?
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
Theories of Ethics
 These are action-guiding theories
 These are systems developed to answer the question “What
do I do?”
1. Utilitarian: the rightness or wrongness of an action depends
on the consequences of that action
2. Deontologic: an action is right or wrong independent of its
consequences
Principle-Based Approach to Ethics
 States that ethical decisions should be based on 5 principles:
1.
2.
3.
4.
5.
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
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
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
Ethical Agency
 The ability to behave in an ethical way and do the right thing because it

1.
2.
3.
4.
5.
6.
7.
is the right thing to do
Requires:
Ethical sensibility
Ethical responsiveness
Ethical reasoning and discernment
Ethical accountability
Ethical character
Ethical valuing
Transformative ethical leadership
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
Ethical decision-making
 Use nursing process:
1.
2.
3.
4.
5.
Assessment: gather all available data
Diagnosis: name the problem/ethical issue
Planning: decide how to deal with this issue
Implementation
Evaluation
Assessment
Evaluation
Implementation
Diagnosis
Planning
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
Ethical Issues for Nurses
 Cost-effectiveness and allocation
 Professional integrity of clinicians
 Issues of cultural and/or religious variations
 Considerations of power
 Unprofessional conduct
Ethics Committees
 Functions:
 Education
 Policy making
 Case review
 Consultation
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
Legal Issues
Law
 Definition:
Standard or rule of conduct established
and enforced by government
Designed to protect the rights of the public
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)
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
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
2. 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
1.
Sources of Law
3.
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
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
2. 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.
3. Under many state and federal laws sanctions may include civil
and criminal penalties
4. In all cases, the defendant is innocent until proven guilty.
1.
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.
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
2. State Boards of Nursing
a. May define nursing practice more specifically (ex: Rules
regarding IV therapy)
3. Professional Boards (ANA)
4. Specialty Nursing Organizations (IV Therapy Nurses Org.;
Nurse Midwifery Org.)
1.
Standards of Care are defined by:
JCAHO requirements
6. Hospital Nursing Policy and Procedures
5.
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)
Standards of Care
 In legal proceedings the legal nurse expert testifies about the
standard of care which may or may not have been violated.
Nurse’s Fiduciary Duty to Client
Must provide knowledgeable and safe care
2. Must behave honestly and truthfully with regard to the
client
3. Must be faithful to provide care in the best interest of the
client
1.
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
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
Civil and Common Law Issues in
Nursing Practice
 Tort: A civil wrong made against a person or property
1. 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
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
Torts: Intentional
 Assault and Battery: Assault is the threat to bring about harm;
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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
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.
Informed Consent
Other legal issues
 Informed Consent:
c. Patient must be capable of giving consent (sedation,
language barriers)
d. Key components: completeness, comprehension,
voluntariness, competence
Legal issues - Student Nurses
Are liable if their actions cause harm to a patient
2. Liability is shared by the instructor, hospital and
educational institution - “Respondent Superior” meaning
the hospital will be held liable for employee/student
actions
3. Student nurses are expected to perform as a professional
LVN would - they are not held to a lower standard of care
4. The LVN or RN assigned to the patient is still responsible
for the patient.
1.
Legal issues - Student Nurses
5.
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
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
MD Orders - Tips
Question any order the client questions
2. Question any order if the patient’s condition has changes
3. Question (read back) and record verbal orders to avoid
miscommunication
4. Question any order which illegible, unclear or incomplete
1.
Tips to avoid malpractice
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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
Tips to avoid malpractice
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8.
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12.
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
Documentation
Documentation
 Purposes for the medical record
1. Communication: means by which health care team members
communicate client needs and progress, therapies, client
education and discharge planning
2. Legal documentation: to limit nursing liability nursing
documentation must clearly indicate that individualized,
goal-directed nursing care was provided to the client based
on the nursing assessment. Nurses need to indicate all
assessments, interventions, client responses, instructions, and
referrals in the medical record
Documentation
 Purposes for the medical record
3. Financial Billing: Reimbursement from insurance companies
and Medicare and Medicaid (DRG’s)
4. Education
5. Research (Requires consent from the patient)
6. Auditing/Monitoring (Quality Improvement)
Incident Reports- Include
 Complete name of person and names of witnesses
 Factual account of incident
 Date, time, and place of incident
 Pertinent characteristics of person involved
 Any equipment or resources being used
 Any other important variables
 Documentation by physician of medical examination of
person involved