TOPIC DESCRIPTION: This topic focusses on the nurses’ ethico- legal responsibilities including the different ethics, values

as well as the legal

concepts that should be kept in mind espeecially in taking care of mentaly ill clients.

CENTRAL OBJECTIVE: Within one- hour lecture-discussion, the learners will acquire knowledge, enhance their beginning
skills and develop desirable attitude in dealing with the clients particularly on the aspect of ethico-legal.

Specific Objectives Content T. A T-L Activities Evaluation

Methods

Within one-hour lecture-

discussion, the learners will:

1) define tghe terms in Prayer

their own words 10 min Assignment
satisfactorily Jesus, Divine Master, I adore You as the Word Incarnate sent by the Father
to instruct men in life-giving truths. You alone have the words of eternal Oral Evaluation through
life. I ask You pardon for all the times that I have not listened to Your situation
Word in the Bible and in the teaching of the Church.

Master, show me the treasures of Your Wisdom. Enlighten my mind and

expel from it all darkness of sin and ignorance. Give me a diligent and
obedient spirit, a quick mind to grasp ideas and a retentive memory. Above
all, assist me with the light of Your Holy Spirit so that I apply my studies
for Your honor, for my salvation and for the good of others.

Introduction
The evolution of humane treatment of mentally ill persons roughly
parallels that of advances made in the jurisprudence system. Historically,
movement has been a slow, cautious process from viewing the mentally ill
as demonic or weak-willed to viewing them as individuals with legitimate
health care problems. Governmental systems and regulatory bodies
thoughtfully attempt to achieve balance between the rights of the
individuals and the rights of society at large.
 The relationship between psychiatry and the law reflects the
tension between individual rights and social needs. Both psychiatry and the
law deal with human behaviour and the relationships and responsibilities
that exist among people. Both also play a role in controlling socially
undesirable behaviour, and together they analyze whether the care
psychiatric patients receive is therapeutic, custodial, repressive, or
punitive.

The legal and ethical context of care is important for all psychiatric
nurses because it focuses concern on the rights of patients and the quality
of care they receive. This knowledge enhances the freedom of both the
nurse and the patient, informs their ethical decision making, and ultimately
results in better care.

I. Definition of Terms
A. Ethics - the study of good conduct, character,
and motives
B. Malpractice - is a type of negligence that refers 10 min
specifically to professionals such as nurses
and physicians
C. Morality - a system of ideas of right and wrong
conduct
D. Negligence - is an unintentional tort that
involves causing harm by failing to do what a
reasonable and prudent person would do in
similar circumstances
E. Restraint - is the direct application of physical
force to a person, without his or her
permission, to restrict his or her freedom of
movement
F. Seclusion - is the involuntary confinement of a
person in a specially constructed, locked room
equipped with a security window or camera for
direct visual monitoring
 G. Tort - is a wrongful act that results in injury,
loss or damage

2) analyze the ethical 45 min Socialized discussion

aspect of PMHN II. Ethical Aspect
correctly A. American Nurses’ Association Code of Ethics
1. The nurse provides services with respect for human dignity
and the uniqueness of the client unrestricted by considerations
f social or economic status, personal attributes, or the nature of
health problems

2. The nurse’s primary commitment is to the patient, whether an

individual, family, group or community

3. The nurse promotes, advocates for, and strives to protect the

health, safety, and rights of the patient

4. The nurse is responsible and accountable fo individual nursing

practice and determines the appropriate delegation of tasks
consistent with the nurse’s obligation to provide optimum
patient care

5. 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

6. The nurse participates in establishing, maintaining, and

improving health care environments and conditions of
employment conducive to the provision of quality health care
and consistent with the values of the profession through
individual and collective action
 7. The nurse participates in the advancement of the profession
through contributions to practice, education, administration,
and knowledge development

8. The nurse collaborates with other health professionals and the

public in promoting community, national, and international
efforts to meet health needs

9. The profession of nursing, as represented by associations and

their members, is responsible for articulating nursing values,
for maintaining the integrity of the profession and it practice,
and for shaping social policy

B. Ethical Responsibility

1. Nurses and self – the nurse has a responsibility to

model health behaviors. Holistic nurses strive to
achieve harmony in their own lives and assist others
striving to do the same

2. Nurses and the client – the nurse’s primary

responsibility is to the client needing nursing care.
The nurse strives to see the client as a whole and
provides care which is professionally appropriate and
culturally consonant. The nurse holds in confidence
all information obtained in professional practice, and
uses professional judgment in disclosing such
information. The nurse enters into a relationship with
the client that is guided by natural respect and a
desire for growth and development

3. Nurses and co-workers – the nurse maintains

cooperative relationship with co-workers in nursing
 and other fields. Nurse have responsibility to nurture
each other, and to assist nurses to work as a team in
the interest of client care. If a client’s care is
endangered by a co-worker, the nurse must take
appropriate action on behalf of the client

4. Nurses and nursing practice – the nurse carries

personal responsibility for practice and for
maintaininng continued competence. Nurses have
the right to utilize all appropriate nursing
interventions, and have the obligation to determine
the efficacy and safety of all nursing actions.
Wherever applicable, nurses utilize research findings
in directing practice

5. Nurses and the profession – the nurse plays a role in

determining and implementing desirable standards
of nursing practice and education. Holistic nurses
may assume a leadership position to guide the
profession toward holism. Nurses support nursing
research and the development of holistically oriented
nursing theories. The nurse participates in
establishing and maintaining equitable social and
economic working conditions in nursing

6. nurses and society – the nurse, along with other

citizens, has responsibility for initiating and
supporting actions to meet the health and social
needs of the public

7. Nurses and the environment – the nurse strives to

manipulate the client’s environment to become one
of peace, harmony, and nurturance so that healing
may take place. The nurse considers the health of
the ecosystem in relation to the need for health,
safety and peace of all persons

C. Ethical Principles – assert that mental health

professionals adopt an attitude of respect for perons,
ensure that clients make their treatment decisions without
coercion (the principle of autonomy) and work for their
client’s well-being (the principle of benifecence). Ethical
standars typically endorse the importance of professional
behevior and responsibility (the principle of fidelity).
Certain activities – for examp, sexual relationships with
clients- are prohibited as being explicitly unethical
because these activities could bring harm to the client (the
principle of nonmaleficence). The principle of justice is
less prominent in professional codes of ethics than are the
other principles. Perhaps this is because in American
society, neither health nor mental health care has been
defined to be a universal right.

D. Ethical Theories
1. Utilitarianism, which focuses on the
consequences of actions. It seeks the greatest amount of
happiness or the least amount of harm for thegreatest
number, or the “greatest good for the greatest number.”
2. Deontology is a theory that says decisions
should be based on whether or not an action is morally
right with no regard for the result or consequences.
Principles used as guides for decision making in
deontology include autonomy, beneficence,
nonmaleficence, justice, veracity and fidelity.
a. Autonomy refers to the person’s right to
self- determination and independence.
b. Beneficence refers to one’s duty to benefit
or to promote good for others.
 c. Nonmaleficence is the requirement to do
no harm to others either intentionally or
unintentionally.
d. Justice refers to fairnee; that is, treating all
people fairly and equally without regard for social
or economic status, race, sex, marital status,
religion, ethnicity, or cultural beliefs.
Veracity is the duty to be honest or truthful.
f. Fidelity refers to the obligation to honor
commitments and contracts.
3. Egoism is a position by which the individual
seeks the solution that is best personally. The self is
3) apply the legalities most important, and others are secondary. 45 mins
of PMHN in 4. Formalism considers the nature of the act itself
different settings and the principles involved. It involves the universal
satisfactorily application of the basic rule, such as “do unto others as
you would have them do unto you.”
5. Fairness is based on the concept of justice, and
benefit to the least advantaged in society becomes the
norm for decision-making.

E. Virtues of PMHN

III. Legal Aspect

A. APA Guidelines on Admission

1. Admission Criteria (Intensity of Service): “There must be

evidence of failure at, inability
to benefit from, or unacceptable risk in an outpatient
treatment setting.”

2. Admission Criteria (Severity of Illness):

“ 1. Threat to self requiring 24-hour professional

observation.
a. Recent suicidal ideation, gesture or attempts within 72
hours prior to
admission.
b. Recent self mutilation (actual threat) within 72 hours
prior to admission.”

3. Physical Exam “A physical exam must be completed to

rule out medical/neurological
causes of psychiatric symptomatology. Several conditions
should be first treated in a
medical ward or even in an intensive care unit prior to the
psychiatric hospitalization.
Examples are drug overdose, anticholinergic delirium, and
neuroleptic malignant
syndrome, among many others.”

4. Active Treatment: “In accordance with the above

definition of ‘improvement,’ the administration of certain
medications such as tranquilizing drugs which are expected
to
significantly alleviate a patient’s psychotic or neurotic
symptoms would be termed active treatment (assuming
the other elements of the definition are met). However, the
administration of a drug or drugs does not itself necessarily
constitute active treatment. Thus the use of mild
tranquilizers for the purpose of relieving anxiety or
insomnia would
not constitute active treatment….”

5. Discharge Criteria (Intensity of Service): “Patients in

inpatient psychiatric care should be
discharged by stepping down to a less intensive level of
outpatient care. ...patients would become outpatients,
receiving either psychiatric partial hospitalization or
individual outpatient mental health services...”
6. Discharge Criteria: “Patients whose clinical condition
improves or stabilizes, who no longer pose an impending
threat to self or others, and who do not still require 24-hour
observation available in an inpatient psychiatric unit should
be stepped down in treatment. Patients whose Global
Assessment of Functioning score is in the range of 30-
45 would usually be appropriate for discharge to a less
intense level of care.”

7. Certification and Recertification: “At the time of

admission or as soon thereafter as is reasonable and
practicable, a physician …must certify the medical
necessity for inpatient psychiatric hospital services. The
first recertification is required no later than the 12th day of
hospitalization. The second recertification is required no
later than the 18th day of
hospitalization.”

8. Initial Psychiatric Evaluation.

9. Plan of Treatment is should always be implemented upon

the patient’s admission

10. Progress Notes – a separate progress note is required

for each service rendered.”

11. Physician Progress Notes – the physician progress notes

should be recorded at each
patient encounter and contain all the information

12. Individual and Group Psychotherapy and Patient

Education and Training Progress Notes.

B. Types of Commitment for Psychiatric Care

Commitment Issues

The decision to become a patient in psychiatric facility is

important. Patients must admit to themselves and to others that self-
management is no lobger a viable for emotional stability. The paradox for
individuals who require inpatient care is that the process of becoming a
patient can itself cause anxiety and might be depressing. The psychiatric
nurse should be aware of this aspect and of the legal status of the patients
in his or her charge.

Voluntary Patients

The cast majority of people with mental health problems are

voluntary patients- that is, they seek help voluntarily. Athough specific
procedure vary from hospital to hospital and from state to state, the basic
procedure is that individuals or their therapists request admission and
patients sign the appropriate documents, including a consent to treatment.
When individuals are ready to leave the treatment setting, they sign
themselves out. Most states have a grace period of 48 to 72 hours to allow
professional staff the time opportunity to assess patients before they leave
voluntarily. Voluntary patients who want to sign themselves out can be
placed on an involuntary commitment status b the court when the staff’s
assessment indicates a need for further treatment.

Involuntary Patients(Commitment)

Mental illness is not equivalent to incompetence. Competence

involves the patient’s ability to comprehend. Involuntary treatment means
that an individual whis has the legal capacity to consent to mental health
treatment refuses to do so. In every state, individuals who are considered
dangerous to self or others because of a mental disorder can be
involuntarily treated for that mental disorder. The U.S. Supreme Court has
repeatedly held, however, that the civil commitment process is subject to
the restrains of the Fourteenth Amendment of the U.S. Constitution. The
state must produce clear and convincing evidence to prove that a person
both mentally ill and dangerous. Failure to comply with these guidelines
can render a commitment illegal. A third criterion-gravely disabled- is also
cause (or required) fir involuntary treatment in many states. Involuntary
treatment is divide into three common categories:

1. Emergency care

2. Short-term observation and treatment

3. Long-term commitment(3, 6,or 12 months)

Not surprisingly, involuntary treatment is the area of psychiatric

care from which most legal issues arise. Although involuntary commitment
usually implies inpatient care, it can also be applied to outpatients
treatment (e.g., group treatment as a consequence for driving under te
influence of alcohol).

Emergency Care

Individuals who meet any one of these three criteria (i.e.,

dangerous to self, dangerous to others, or gravely disable) can be detained
involuntarily for evaluation and emergency treatment in most states. An
authorized person such as a police officer signs documents to place and
individual under involuntary care. The length of the involuntary status
varies form state to state; typically, 48 to 72 hours is the average.

Nursing Implications

Because the law determines the length of this involuntary

treatment period, staff must scrupulously adhere to legal time constraints.
The nursing staff must be absolutely aware of the point at which the
emergency treatment period is over and prepare the patient for discharge at
that time. Patients might be asked to remain voluntarily in the facility and,
if they refuse, they might then be asked to sign out against medical service.

Short-term Observation and Treatment

Each state has laws that provide for short-term observation and
treatment for mental illness. These laws, which differ from state to state,
authorize a qualified expert to determine whether a person has a treatable
mental disorder. In most states, a qualified expert might be a physician, a
psychiatrist, a master’s-prepared nurse or social worker, or a psychologist.
A treatable mental disorder indicates that the problem is amenable to and
can improve with treatment. For example, a person meets this criterion,
whereas someone who is simply angry and threatening to kill someone
might not.

If, during the emergency evaluation period, it is suspected that

further hospitalization is needed, a certification hearing takes place, a
complaint or a probable cause statement is written, indicating that the
person is a danger to self or others or is gravely disabled. The probable
cause statement us required by the Fourth Amendment to the U.S
Constitution, which prohibits “search and seizure of a person without
probable cause.” In this context, probable cause means that known facts
would lead an ordinary person to believe that the person detained is
mentally disordered and is a danger to self or others or is gravely disabled.
The probable cause hearing is not held to determine whether the person is
mentally ill, but whether the person is mentally ill, but whether just cause
exists to keep the person for treatment against his or her will.

If probable cause exists, individuals can then be detained for

observation and treatment. These individuals must be informed of their
rights on being certified for this level of involuntary care. The length of the
observation and treatment period varies from state to state.
Nursing Implications

Patients must be released when no legal basis exists for continued

confinement in the hospital. The hospital staff might suggest voluntary
admission and, if it is refused, might require patients to sign out against
medical advice. The staff cannot hold someone simply because they
believe that the individuals needs to be protected form herself or himself.

Long-term Commitment

Long-term commitment is reserved for persons who need

prolonged psychiatric care but refuse to seek such help voluntarily. These
hospitalizations can last from about 90 days to much longer. Such
individuals are usually brought before a hearing officer, which is a major
part of the system of checks and balances that decreases the possibility of
someone being railroaded into a mental hospital.

Commitment of Incapacitated Persons

In most places, a procedure is required for establishing a

conservator or guardian for a gravely disabled person (the conservatee)
because adults are presumed competent before the law. The legal system in
the United States maintains that, although a person might be undergoing
severe mental and emotional upheaval, that person is nonetheless
recognized as competent. The person who is identified as being gravely
disabled, on the other hand, is viewed by the legal system as incompetent.
Once judged incompetent, the individual loses rights such as the right to
marry, vote, drive a car, and enter into contracts.

Gravely disabled is defined as the inability to provide food, clothing, and

shelter for oneself because of a mental illness. This does not mean that all
people living on the streets are gravely disabled, nor that they should be
hospitalized for their own good. However, people with money in their
pockets who cannot negotiate arrangements for food or shelter are gravely
disabled.

Conservators and Guardians

The appointment of a conservator or guardian is a serious legal

matter, and full legal protection is provided for persons being evaluated for
conservatee status. The proposed conservatee is entitled to representation
by an attorney to challenge conservatorship. An appointed conservator or
guardian can be given broad powers, including the right to order the
conservatee to receive psychiatric treatment. Technically, although patients
might receive treatment against their will, a legal distinction exists between
this type of commitment and an involuntary commitment. That distinction
is based on the premise that the conservator now speaks for the patient;
hence, the treatment is not involuntary. Conservators are legally obliged to
act in the best interest of their conservatees.

Nursing Implications

Because conservators speak for conservatees, the nurse must

obtain consent from conservators for decisions that are otherwise made by
patients. A nurse who forgets to obtain conservator approval might face
legal consequences.

C. Patient’s Rights

In addition to the information discussed in the following section,

the Federal Register, published by the Centers for Medicare and Medicaid
Services (CMS), is a good source of information about patient rights and
regulations. Aside from the legal and patient care issues, these rights must
be assured for health care providers so they can participate in the Medicare
and Medicaid programs.
Right to Treatment with the Least Restrictive Environment

The concept of the least restrictive alternative or least restrictive

environment is central to the ideology of the deinstitutionalization
movement. People with mental health problems have the right to treatment
of their problems in the least restrictive environment using the least
restrictive means (i.e., without restraints and seclusion, unless necessary).

Nursing Implications

The nurse has treatment responsibilities and can be held liable if

the patient does not receive adequate treatment.

Right to Confidentiality of Records

Patient information is privileged material and should be treated

confidentially. Both voluntary and involuntary patients are granted this
legal consideration. Following this procedure is not always as easy as it
might appear hence professional judgment is required.

As straightforward as these guidelines are, they do not cover every

situation or address exceptions. The rule of confidentiality is not absolute.
For example, information about a patient at risk for self-harm must be
made available to appropriate individuals. Keeping this type of information
confidential constitutes professional malpractice.

Tips for Monitoring Confidentiality

1. Keep all patient records secure.

2. Carefully consider the content of all written entries.
3. Release information only with written consent.
4. Disguise clinical material when it is used for educational
purposes.
 5. Share information only with people who need to know, not
with friends or in public areas.
6. Guard written material taken outside the clinical area.
7. Do not access written or electronic information out of
curiosity.
8. Fax transmissions to unsecured areas in which a receipt
error is a possibility might be prohibited.
9. Know to whom you are talking when relating patient
information over the phone; “family” might be a reporter, boss, or
insurance attorney.

Health Insurance Portability and Accountability Act

The Health Insurance Portability and Accountability Act (HIPAA)

took effect in April 2003. Because modern technology is often a two-edged
sword, concerns have arisen over its misuse. For example, even though
computer technology speeds the transfer and storage of personal medical
information, it has also proven to be avenue for invasion of privacy.
HIPAA gives patients more control over their medical records. It also
creates stiffer penalties for those who handle a patient’s medical record in
too cavalier a manner. Appelbaum (2002) has outlined the four rights that
patients have under HIPAA legislation:

1. Right to be educated about HIPAA privacy regulations

2. Right to access their own medical records
3. Right to correct or add to their medical records
4. Right to demand their authorization before their medical
records are disclosed to others

Nursing Implications

The nurse should document all confidential information that is

released in the nursing notes, including the date and circumstances under
which disclosure was made, the names of the individual or agencies
receiving the disclosure and their relationship(s) to the patient, and the
specific information disclosed.

To release information about patients, a consent form must first be

signed. Most states provide legal redress for patients if a nurse wilfully
discloses confidential information without the proper signature.
Confidentiality of the patient’s records should not be confused with the
doctrine of privileged communication. Under this doctrine, a psychiatrist is
not obliged to reveal the contents of sessions with the patient, a privilege
that is based on the understanding of the need for trust between physicians
and patients. Most states do not include nurses under this provision.

The therapeutic modality of group therapy, which nurses often

lead, is particularly vulnerable to violations of confidentiality. The group
leader should always address this issue when starting a group or when a
new member is introduced to the group. Nurses who lead group sessions
must acknowledge the limitations to confidentiality that exist in the group
format. After such a proclamation is made, forthrightness by group
members concerning their thoughts, feelings, and behaviours might
decline. It is absolutely necessary that staff not discuss patients in settings
in which those without a clinical need to know can overhear those
conversations.

Right to Freedom from Restraints and Seclusion

Throughout history, mechanical restraints and segregation have

been used to manage the out of control behaviour that accompanies some
psychiatric disorders. Restraint is a broad term used to characterize any
form of limiting a person’s movement or access to his or her own body.
The limits can be the result of physical holds, bed rails, lap trays, restraint
devices, or medications. Seclusion is defined as the process of isolation a
person in a room in which they are physically prevented from leaving. The
real value of judiciously used restraint and seclusion to protect severely ill
patient and those with whom they come into contact has been
overshadowed in recent years by attention to injuries and deaths associated
with their use. The U.S. Food and Drug Administration (FDA) has
estimated that at least 100 restraint-related deaths occur each year. In some
instances, restraints and seclusion have been substituted for more
appropriate management interventions. The patient’s right to the least
restrictive interventions to manage behavioural disturbances has been
violated, with resulting disability, injury, and death.

The 1987 Omnibus Reconciliation Act (OBRA) placed stringent limits on

the use of physical and chemical restraints (e.g., antipsychotics,
benzodiazepines) in nursing homes to ensure that their use is limited to
medical necessity, not staff convenience. Many nursing homes have since
implemented innovative strategies to preserve the safety of frail older
adults, with a goal of becoming restraint free. The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) has developed
standards to guide efforts to reduce the use of restraints in both medical
and psychiatric facilities. The CMS has also published, within their
Patients Rights document, strict rules for restraint and seclusion use in
hospitals that receive Medicare and Medicaid funds (Medicare and
Medicaid programs, 1999).

Nursing Implications

Reduction in the use of restraints is difficult to achieve given the

rather prevalent belief that a restrained patient is a safe one. Nurses who
are aware of the potential negative physical, psychological, and legal
consequences associated with restraint and seclusion are more apt to look
for alternate strategies. Most valuable are those interventions aimed at
preventing a patient’s escalation in behaviour and loss of control. Attention
to the nurse-patient relationship, therapeutic milieu, and principles of
pharmacologic management can reduce the need for restrictive measures.
 Although law differ from state to state, general guidelines for use
in psychiatry include multiple elements important for the nurse to
document:

1. Staff members involved in decisions to restrain or seclude and

those who apply or remove restraints must receive special training
and demonstrate competency.
2. Alternatives to restraint and seclusion must be considered before
their use.
3. Although nurses might be allowed to implement restraint or
seclusion in emergent situations, a physician’s order is required
within 1 hour. Physician assistants and advanced practice nurses
can also write restraint and seclusion orders.
4. The least restrictive method or device possible must be chosen.
5. Nurses should carefully document events leading up to the
intervention and justification for use.
6. Orders must contain the type of restraint, rationale for use, and
time limitations.
7. As needed (prn) orders are not permitted. Each episode must be
based on eminent risk.
8. Restraint and seclusion are used for the shortest possible time. The
nurse must tell the patients what behaviours are expected before
release and reevaluate the patients at least every 2 hours for
continued necessity.
9. Patients must be observed constantly during restraint and seclusion
with documentation of safety and comfort interventions at least
every 15 minutes.
10. Patients must be debriefed after restrictive interventions.
11. Patients have the right to request notification of a family member
or other person in the event that restraints or seclusion are
implemented.
12. Death of any patient while in restraints, even when restraints did
not contribute to death in the judgment of the health care provider,
is required to be reported to the FDA (in the US).
Right to Give or Refuse Consent to Treatment

The right of voluntary patients to refuse treatment has been

recognized for a long time. When voluntary patients believe that the
treatment they are receiving is helpful, they can accept it; when they
believe that the treatment is not helpful, they can refuse it. Involuntary
patients, on the other hand, have not always been understood to have the
same right to refuse treatment. Through the years, many involuntary
patients have been forced to take medications against their will. Legally,
involuntarily admitted patients do not lose their right to give informed
consent to the administration of psychotropic drugs. The key issue is
whether patients have the capacity to give informed consent to the
administration of these drugs. After the court decides tat a person is not
competent to understand the need for treatment, medications can then be
imposed on that person. The way in which this decision is implemented
varies from state to state.

In cases of a psychiatric emergency, medications can be given without

consent to prevent harm to the patient or to others.

Nursing Implications

Nurses administer medications to patients. Because it is not

uncommon for patients to refuse medications and for nurses to coax those
patients into taking medications, nurses must be sure that coaxing does not
escalate to the point of forcing medication on a patient. Furthermore,
although it might be tempting to hide medications in food or liquid when
patients refuse them, these actions are considered forcing. The deception is
also counter-productive when trying to establish a therapeutic nurse-patient
relationship. Factors that constitute a psychiatric emergency are also not
always clear. Nurses might be held liable if their interpretation of a
psychiatric emergency differs from that of another professional or a judge.
 D. Nursing Liabiltiy
Nurses are responsible for providing safe, competent, legal, and ethical
care to clients and families. Nurses are expected to meet standards of
care, meaning the care they provide to clients meet set expectations
and is what any nurse in a similar situation would do. Standards of care
are developed from professional standards, state nurse practice acts,
federal agency regulations, agency policies and procedures, job
descriptions, and civil and criminal laws.

Torts

A tort is a wrongful act that results in injury, loss or dmage. Torts may
be either unintentional or intentional.

Unintentional torts: Negligence and Malpractice

Negligence is an unintentional tort that involves causing harm by

failing to do what a reasonable and prudent person would do in similar
circumstances. Malpractice is a type of negligence that refers
specifically to professionals such as nurses and physicians. Clients and
families can file malpractice lawsuits in any case of injury, loss, or
death. For a malpractice suit to be successful, that is, for the nurse,
physicians, or hospital or agency to be liable, the client or family needs
to prove the following four elements:

1. Duty. A legally recognized relationship (i.e., physician to client

nurse to client) existed. The nurse had a duty to the client, meaning
that the nurse was acting in the capacity of the nurse.
2. Breach of Duty. The nurse (or physician) failed to conform to
standards of care, thereby breaching or failing the existing duty.
The nurse did not act as a responsible, prudent nurse would have
acted in similar circumstances.
3. Injury or damage. The client suffered some type of loss, damage or
 injury.
4. Causation. The breach of duty was the direct cause of the loss,
damage or injury. In other words, the loss damage or injury would
not have occurred if thenurse had acted in a reasonable, prudent
manner.

Intentional Torts. Psychiatric nurses also may be liable for intentional torts
or voluntary acts that result in harm to the client. Examples include assault,
battery and false imprisonment.

Assault involves any action that causes a person to fear being touched in a
way that is offensive, insulting or physically injurious without consent or
authority. Examples include making threats to restrain the client to give
him or her an injection for filur to cooperate. Battery involves harmful or
unwarranted contact with a client; actual harm or injury may or may not
have occurred. Examples include touching a client without consent or
unnecessarily restraining a client. False Imprisonment is defined as the
injustifiable detention of a client such as the inappropriate use of restraint
or seclusion.

Providing liability for an intentional tort involves three elements:

1. The act was willful and voluntary on the part of the defendant
(nurse).
2. The nurse intended to bring about consequences or injury to the
person (client).
3. The act was a substantial factoring causing injury or consequences.
Prevention of Liability

Through safe competent nursing care and descriptive, accurate

dociumentation, the nurse can minimize the risk for lawsuits.

Ways to minimize the risk for liability:

1. practice within the scope of state laws and nurse practice act.
 2. collaborate with colleagues to determine the best course of action.
3. use established practice standards to guide decisions and actions.
4. Always put the the client’s rights and welfare first.
5. Develop effective interpersonal relationships with clients and
families.
6. Accurately and thoroughly document all assessment data,
treatments, interventions and evaluations of the client’s response
to care

E. Filipino Bill of Rights

Title 111: Declaration of Rights

Sec. 4. The Rights of Patients. - The following rights of the patient shall be

respected by all those involved in his care:

(1) Right to Appropriate Medical Care and Humane Treatment. - Every

person has a right to health and medical care corresponding to his state of
health, without any discrimination and within the limits of the resources,
manpower and competence available for health and medical care at the
relevant time.

The patient has the right to appropriate health and medical care of good
quality.

In the course of such care, his human dignity, convictions, integrity,

individual needs and culture shall be respected.

If any person cannot immediately be given treatment that is medically

necessary he shall, depending on his state of health, either be directed to
wait for care, or be referred or sent for treatment elsewhere, where the
appropriate care can be provided. If the patient has to wait for care, he
shall be informed of the reason for the delay.

Patients in emergency shall be extended immediate medical care and

treatment without any deposit, pledge, mortgage or any form of advance
payment for treatment.

(2) Right to Informed Consent. - The patient has a right to a clear, truthful
and substantial explanation, in a manner and language understandable to
the patient, of all proposed procedures, whether diagnostic, preventive,
curative, rehabilitative or therapeutic, wherein the person who will perform
the said procedure shall provide his name and credentials to the patient,
possibilities of any risk of mortality or serious side effects, problems
related to recuperation, and probability of success and reasonable risks
involved: Provided, That, the patient will not be subjected to any
procedure without his written informed consent, except in the following
cases:

a. in emergency cases, when the patient is at imminent risk of physical

injury, decline or death if treatment is withheld or postponed. In such
cases, the physician can perform any diagnostic or treatment procedure as
good practice of medicine dictates without such consent;

b. when the health of the population is dependent on the adoption of a mass

health program to control epidemic;

c. when the law makes it compulsory for everyone to submit to a

procedure;

d. when the patient is either a minor, or legally incompetent, in which case,

a third party consent is required;

e. when disclosure of material information to patient will jeopardize the

success of treatment, in which case, third party disclosure and consent shall
be in order;

f. when the patient waives his right in writing.

Informed consent shall be obtained from a patient concerned if he is of

legal age and of sound mind. In case the patient is incapable of giving
consent and a third party consent is required, the following persons, in the
order of priority stated hereunder, may give consent:

i. spouse;
ii. son or daughter of legal age;
iii. either parent;
iv. brother or sister of legal age, or
v. guardian
If a patient is a minor, consent shall be obtained from his parents or legal
guardian.

If next of kin, parents or legal guardians refuse to give consent to a medical

or surgical procedure necessary to save the life or 1imb of a minor or a
patient incapable of giving consent, courts, upon the petition of the
physician or any person interested in the welfare of the patient, in a
summary proceeding, may issue an order giving consent.

(3) Right To Privacy and Confidentiality. - The privacy of the patients

must be assured at all stages of his treatment. The patient has the right to
be free from

unwarranted public exposure, except in the following cases:

a) when his mental or physical condition is in controversy and the

appropriate court, in its discretion, orders him to submit to a physical or
mental examination by a physician;

b) when the public health and safety so demand; and c) when the patient
waives this right.

The patient has the right to demand that all information, communication
and records pertaining to his care be treated as confidential. Any health
care provider or practitioner involved in the treatment of a patient and all
those who have legitimate access to the patient's record is not authorized to
divulge any information to a third party who has no concern with the care
and welfare of the patient without his consent, except:

a) when such disclosure will benefit public health and safety;

b) when it is in the interest of justice and upon the order of a competent

court; and c) when the patients waives in writing the confidential nature of
such information; d) when it is needed for continued medical treatment or
advancement of medical science subject to de-identification of patient and
shared medical confidentiality for those who have access to the
information.

Informing the spouse or the family to the first degree of the patient’s
medical condition may be allowed; Provided, That the patient of legal age
shall have the right to choose on whom to inform. In case the patient is not
of legal age or is mentally incapacitated, such information shall be given to
the parents, legal guardian or his next of kin.

(4) Right to Information. - In the course of his/her treatment and hospital

care, the patient or his/her legal guardian has a right to be informed of the
result of the evaluation of the nature and extent of his/her disease, any
other additional or further contemplated medical treatment on surgical
procedure or procedures, including any other additional medicines to be
administered and their generic counterpart including the possible
complications and other pertinent facts, statistics or studies, regarding
his/her illness, any change in the plan of care before the change is made,
the person’s participation in the plan of care and necessary changes before
its implementation, the extent to which payment maybe expected from
Philhealth or any payor and any charges for which the patient maybe
liable, the disciplines of health care practitioners who will furnish the care
and the frequency of services that are proposed to be furnished.

The patient or his legal guardian has the right to examine and be given an
itemized bill of the hospital and medical services rendered in the facility or
by his/her physician and other health care providers, regardless of the
manner and source of payment. He is entitled to a thorough explanation of
such bill. The patient or his/her legal guardian has the right to be informed
by the physician or his/her delegate of his/her continuing health care
requirements following discharge, including instructions about home
medications, diet, physical activity and all other pertinent information to
promote health and well-being.

At the end of his/her confinement, the patient is entitled to a brief, written

summary of the course of his/her illness which shall include at least the
history, physical examination, diagnosis, medications, surgical procedure,
ancillary and laboratory procedures, and the plan of further treatment, and
which shall be provided by the attending physician. He/she is likewise
entitled to the explanation of, and to view, the contents of the medical
record of his/her confinement but with the presence of his/her attending
physician or in the absence of the attending physician, the hospital’s
representative.

Notwithstanding that he/she may not be able to settle his accounts by

reason of financial incapacity, he/she is entitled to reproduction, at his/her
expense, the pertinent part or parts of the medical record the purpose or
purposes of which he shall indicate in his/her written request for
reproduction. The patient shall likewise be entitled to medical certificate,
free of charge, with respect to his/her previous confinement.

The patient has likewise the right not to be informed, at his/her explicit
request.

(5) The Right To Choose Health Care Provider and Facility. - The patient
is free to choose the health care provider to serve him as well as the facility
except when he is under the care of a service facility or when public health
and safety so demands or when the patient expressly or impliedly waives
this right.

The patient has the right to discuss his condition with a consultant
specialist, at

the patient’s request and expense. He also has the right to seek for a second
opinion and subsequent opinions, if appropriate, from another health care
provider/practitioner.

(6) Right to Self-Determination. - The patient has the right to avail

himself/herself of any recommended diagnostic and treatment procedures.
Any person of legal age and of sound mind may make an advance written
directive for physicians to administer terminal care when he/she suffers
from the terminal phase of a terminal illness: Provided, That

a) he is informed of the medical consequences of his choice;

b) he releases those involved in his care from any obligation relative to the
consequences of his decision;

c) his decision will not prejudice public health and safety.

(7) Right to Religious Belief. - The patient has the right to refuse medical
treatment or procedures which may be contrary to his religious beliefs,
subject to the limitations described in the preceding subsection: Provided,
That such a right shall not be imposed by parents upon their children who
have not reached the legal age in a life threatening situation as determined
by the attending physician or the medical director of the facility.
(8) Right to Medical Records. - The patient is entitled to a summary of his
medical history and condition, He has the right to view the contents of his
medical records, except psychiatric notes and other incriminatory
information obtained about third parties, with the attending physician
explaining contents thereof. At his expense and upon discharge of the
patient, he may obtain from the health care institution a reproduction of the
same record whether or not he has fully settled his financial obligation
with the physician or institution concerned.

The health care institution shall safeguard the confidentiality of the

medical records and to likewise ensure the integrity and authenticity of the
medical records and shall keep the same within a reasonable time as may
be determined by the Department of Health.

The health care institution shall issue a medical certificate to the patient
upon request. Any other document that the patient may require for
insurance claims shall also be made available to him within a reasonable
period of time.

(9) Right to Leave. - The patient has the right to leave a hospital or any
other health care institution regardless of his physical condition: Provided,
That

a) he/she is informed of the medical consequences of his/her decision;

b) he/she releases those involved in his/her care from any obligation

relative to the consequences of his decision;

c) his/her decision will not prejudice public health and safety.

No patient shall be detained against his/her will in any health care

institution on the sole basis of his failure to fully settle is financial
obligations. However, he/she shall only be allowed to leave the hospital
provided appropriate arrangements have been made to settle the unpaid
bills: Provided, farther, that unpaid bills of patients shall be considered as
lost income by the hospital and health care provider/practitioner and shall
be deducted from gross income as income loss for that particular year.

(10) Right to Refuse Participation in Medical Research. - The patient has

the right to be advised if the health care provider plans to involve him in
medical research, including but not limited to human experimentation
which may be performed only with the written informed consent of the
patient. Provided, further, That, an institutional review board or ethical
review board in accordance with the guidelines set in the Declaration of
Helsinki be established for research involving human experimentation:

Provided, finally, That the Department of Health shall safeguard the

continuing training and education of future health care
provider/practitioner to ensure the development of the health care delivery
in the country.

(11) Right to Correspondence and to Receive Visitors - The patient has the
right to communicate with relatives and other persons and to receive
visitors subject to reasonable limits prescribed by the rules and regulations
of the health care institution.

(12) Right to Express Grievances. - The patient has the right to express
complaints and grievances about the care and services received without
fear of discrimination or reprisal and to know about the disposition of such
complaints. The Secretary of Health, in consultation with health care
providers, consumer groups and other concerned agencies shall establish a
grievance system wherein patients may seek redress of their grievances.
Such a system shall afford all parties concerned with the opportunity to
settle amicably all grievances.

(13) Right to be Informed of His Rights and Obligations as a Patient. – 10 min

Every person has the right to be informed of his rights and obligations as a
 patient. The Department of Health, in coordination with health care
providers, professional and civic groups, the media, health insurance
corporations, people’s organizations, local government organizations, shall
launch and sustain a nationwide information and education campaign to
make known to people their rights as patients, as declared in this Act. Such
rights &d obligations of patients shall be posted in a bulletin board
conspicuously placed in a health care institution.

It shall be the duty of health care institutions to inform patients of their

rights as well as the institution's rules and regulations that apply to the
conduct of the patient while in the care of such institution.

IV. Evaluation of the Wardclass

REFERENCES:

Potter, P.A & Perry A. G.(2001). Fundamentals of nursing. (5th Ed.). USA: Mosby, Inc.
Kozier, B. et al. (2004). Fundamentals of nursing: concepts, process and practice. (7th ed). Upper Saddle
River, Ney Jersey: Pearson Education, Inc.
Stuart, G.W. & Laraia, M. T. (2001). Principles and practice of psychiatric nursing.(7th ed). USA: Mosby,
Inc.
Videbeck, S.L. (2004). Psychiatric mental health nursing. (2nd ed). Philippines: Lippincott William and
Wilkins.
Frisch, N. C.(2002). Psychiatric mental health nursing: understanding the client as well as the condition.
(2nd ed). USA: Delmar
Keltner, N. I.& et al.(2002). Psychiatric nursing. (3rd ed). Philippines.