1. What is the importance of law to the practice of Nursing?

What is your
understanding of R.A. 9173? What are some points in order to avoid criminal / civil
liability?

In every nurse's career, he or she will face with legal and ethical dilemmas. One of the
professional competencies for nursing states that nurses should "Integrate knowledge of
ethical and legal aspects of health care and professional values into nursing practice. “ It is
important to first understand the difference between law and ethics. Ethics examines the
values and actions of people. Often times there is no right course of action when one is faced
with an ethical dilemma. On the other hand, laws are binding rules of conduct. When laws are
broken, it is punishable by an authority figure.

Legal aspects of nursing that are associated with helping and caring for people in the
health care industry have become an important prerequisite to be aware of. Cases of
negligence are on the rise and this result to less people wanting to get into the health care
industry with fear of legal aspects and inevitable law suits.

RA 9173 in an act providing for a more responsive nursing profession, repealing for the
purpose RA 7164 known as the “Phil. Nursing Act of 1991 and for other purposes. This act shall
be known as the “Phil. Nursing Act of 2002”. Thus, every Filipino nurse must know the RA
9173, to protect and improve the nursing profession in the country, to improve nursing
education and dignify the existence of nurses. Especially now, thousands of nurses are being
abused in false volunteerism and false salary or benefits.

Nursing law serves a number of functions: establishes which nursing actions in the care
of patient are legal, separates nurses responsibilities from those of other health professional,
maintains a standard of nursing practice by ensuring nurses are accountable under the law
and it assists in establishing the boundaries of independent nursing action. Nurses are bound
by the nursing practice act that stipulates rules and regulations which are determined by the
legislature. Nursing practice falls both under public and civil laws. Public laws protect the
public while civil law deals with conflicts between a nurse and a patient.

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 A nurse can lose his or her license to practice if he or she violates a public law. For
example if a nurse is found guilty of diverting drugs which is a crime against the state and the
public, leads to incarceration. Legal aspects need to be applied by nurses in their roles and
ensure that necessary care is present in maintaining the health and safety of patients.

Below are some points in order to avoid Criminal / Civil Liability?

 Be very familiar with the Philippine Nursing Law.

 Be aware of the laws affecting nursing practice.
 At the start of employment, know agency rules, regulations and policies.
 Upgrade your skills and competence.
 Accept only such responsibility that is within the scope of your responsibilities.
 Determine whether your subordinates are competent in the work you are
assigning them.
 Develop good IPR with your co-workers.
 Consult your superior for problems that may be too big to handle.
 Verify orders that are not clear or those that seem to be erroneous.
 The doctors should be informed about the patient’s condition, effects of
medications and treatments and patient’s lack of progress.
 Ensure accurate recording and reporting. “Whatever is not written was not
done. Whatever is written has been done.” Include date and time.
 Patients are entitled to informed consent.
 Do not delegate your responsibilities to others.

In conclusion, nursing students and nurses should be aware of their legal responsibility
and that is to do no patient intentional harm since a nurse is responsible for a patient’s care.
A nurse should be competent in practice and be aware that any negligent act in the line of
profession may become a malpractice law suit.

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 2. Clear, complete and accurate health records serve many purposes for client,
families, registered nurses and other care providers. Give the importance of
documentation in nursing and what should be documented? Cite 3 problems /
situation arising from poor documentation and communication and the legal
implications that may lead to the revocation of license.

Professional Standards are necessarily required for nurses to document timely and
accurate reports of relevant observations, including conclusions drawn from those
observations. Documentation is any written or electronically generated information about a
client that describes the care or service provided to that client.

Documentation is an accurate account of what occurred and when it occurred. Nurses

may document information pertaining to individual clients or groups of clients. Individual
Clients when caring for an individual client (which may include the client’s family), the nurse’s
documentation provides a clear picture of the status of the client, the actions of the nurse,
and the client’s outcomes. Nursing documentation clearly describes: an assessment of the
client’s health status, nursing interventions carried out, and the impact of these interventions
on client outcomes; a Care plan or Health plan reflects the needs and goats of the client;
needed changes to the care plan; information reported to a physician or other health care
provider and when appropriate, that provider’s response; and advocacy undertaken by the
nurse on behalf of the client.

Documentation focuses on patient data in relation to the nursing and medical

observations and therapies in the Critical units and the use of a ‘Plow Chart’ is to improve the
present documentation system. It provides continuous monitoring and in most cases provides
criteria for admission to the unit and these criteria may include such conditions as multi-
trauma, drug overdose, post-operative major vascular surgery, cardio-pulmonary arrest and
sepsis. The current process of documentation involves numerous and separate charts.

Documentation encourages nurses to assess client progress and determine which

interventions are effective and ineffective, and identify and document changes to the plan of
care as needed. Documentation can be a valuable source of data for making decisions about
finding and resource management as well as facilitating nursing research, all of which have
the potential to improve the quality of nursing practice and client care.

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Key Components of Nursing Documentation

COMPONENT DESCRIPTION

Include assessments and reassessments that are ongoing.

Assessments Routine frequency is determined by health care organization
policy

Identify patient
needs or nursing Includes documentation on a problem list or a care plan and
diagnoses sometimes on an assessment. Health care organizations are
increasingly using standardized diagnoses

Include a separate care plan or p care documentation on

Planned care
progress notes or separate guidelines for care

Revisions of Includes reasons for change, supporting evidence, and

planned care agreement from patient or family for the revised plan of care

Includes patient observations, treatment interventions,

Nursing
teaching, clinical judgment& Document on flow sheets and
Interventions
progress notes

Includes learning needs, teaching plan content, mode of

Patient teaching instruction, (who and what were taught), patient response and
comprehension

Includes the following:

 Patient progress toward goals (expected outcomes)

 Patient response to tests, treatments, nursing intervention
Patient out come
 Patient, family response to significant events
 Questions, statements, complaints voiced by patient or
family

Interdisciplinary Includes communication with physician and other disciplines

communication & and their outcomes. Mostly this occurs in form of referral in
team conferences multi problems diagnosed clients

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 DOCUMENT INFORMATION

Lists biographical data (name, date of birth, address, phone

Face sheet number, social security number, marital status, employment,
race, gender, religion, closest relative); insurance coverage,
allergies, attending physician, admitting medical diagnosis,
assigned diagnosis-related group, statement of whether the
client has an advance directive or not.

Include the following:

 Admit: permission given to institution and physician to treat

 Surgery: explains the reason for the operation in lay terms;
the risks for complications; and the client’s level of
Consent form understanding
 Blood transfusion: grants permission to administrator blood
or blood products
 Medico legal or Non- Medico legal: grants permission to
physician and nurses to deal accordingly
 Various others: grant permission to participate in research,
have photograph taken, and to know HIV status

Medical history
Details results of the client’s initial history and physical
and Physical
assessment as performed by the physician and nurses
examination

Physician’s order Outlines medical orders to admit; the treatment plan and
sheet complete medication information

Delineates physician’s evaluation of the client’s response to

Physician progress
treatment; may also contain the progress recording of other
notes
practitioners, e.g., dietary or social services

Initiated by the physician to request the evaluation or services of

Consultation sheet other practitioners. It is also called referral or exerts opinion
form of the secondary specialties

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Diagnostic results Contains the results from laboratory and diagnostic tests

Nursing admit Records data obtained from the interview and physical
assessment sheet assessment conducted by the nurses

Contains the treatment plan, e.g., nursing diagnosis or a problem

Nursing care plan
list, initiation of standards of care, or protocols

Graphic sheet List data related to vital signs and weight

Contains all routine interventions that can be indicated via a

Flow sheet check mark or other simple code; allows for a quick comparison
of measurements

Details of additional data without duplication information on the

Nurse’s progress
flow sheet, e. g., client’s achievement of expected outcome,
notes
revision of the plan of care

Medication Contains all medication for routine and PRN (as needed) thugs:
administration date, tine, dose, route, site (for administration), form of
record(MAR) medicines and course of medication

Client education Record both the nurses’ educational efforts directed toward the
record client family, or other care giver and the learner’s response

Serves as the treatment and progress record for non-medical

Health care team and non-nursing practitioners (e.g., respiratory, physical therapy,
record dietary) when the physician’s progress notes are not used by
those practitioners

A multidisciplinary form for each day of anticipated

hospitalization; identifies the interventions and achievements of
Critical pathway
client outcomes; in the progress notes, explains the initial
practitioner’s implementation and the variances from the norm

A multidisciplinary form used before discharging from a health

Discharge plan and care facility which contains a brief summary of care rendered and
summary discharge instructions (e.g., food-drug interactions or follow-up
appointments)

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 Federal law requires that health care providers discuss with the
client the use of advance directives, a living will or a durable
Advance directive
power of attorney. Most states recognize living will as a legal
or living will
document. If the client has advance directives, they are reviewed
at the time of admission and placed in the medical record

To meet professional and legal standards: Documentation is a valuable method for

demonstrating that, within the nurse-client relationship, the nurse has applied nursing
knowledge, skills and judgment according to professional standards. The nurse’s
documentation may be used as evidence in legal proceedings such as lawsuits, coroners’
inquests, and disciplinary hearings through professional regulatory bodies. In a court of law,
the client’s health record serves as the legal record of the care or service provided. Nursing
care and the documentation of that care will be measured according to the standard of a
reasonable and prudent nurse with similar education and experience in a similar situation. In
these circumstances, the documentation will be closely and carefully scrutinized and the
standard of care given will be expected to be reflected by the standard of documentation. An
absence of documentation would ordinarily be interpreted as inferring that nothing was done
in a particular circumstance. Poor standards of nursing documentation are regarded as
contributing to poor quality nursing care. If nursing documentation is inaccurate, problems
may arise as follows:

• Researchers wouldn't be able to conduct patient-related studies

• Safe patient care is compromised due to a nurse's incomplete/inaccurate clinical chart

• Reimbursement/gross revenue is decreased

• Findings of fraud and abuse will lead to federal prosecution

Incomplete nursing documentation in patient clinical records can cause your

organization legal and settlement fees, you lose your nursing license, contribute to inaccurate
statistical databases, cause lost revenue/reimbursement, and result in poor patient care by
other healthcare team members.

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 3. Cite 5 situations in the workplace whether it be in the hospital or community
environment where one or more ethical principles are involved. Give some resolution
to the problem / situation presented utilizing the decision – making process.

A. Truth – Telling

Truth-telling states that the physician will tell the whole truth, not a half-truth or white
lie. The truth is required even when, in the physician’s opinion, it would harm the patient’s
psychological well-being. A dilemma arises when the patient’s desires run counter to truth-
telling. Consider the situation of the unusual patient who says, I don’t want to know any bad
news. Just figure out what is wrong, and treat me as best you can! You want to respect the
patient’s request, but you also know that the patient has cancer and will need to make
informed decisions about staging and treatments. You know that you cannot make the
decisions for the patient because the decisions involve alternative approaches that depend
on personal values and goals. You must balance the application of truth-telling with the
application of autonomy.

Trust-which is built on truth-telling, beneficence, and non-maleficence has additional

implications in the patient-physician relationship. Trust allows for mutual win-win problem
solving. It allows a patient to place his or her welfare in the hands of the physician, but also
convinces patients that their physician is not directly responsible for sub-optimal medical
outcomes.

Situation: You have been the primary care physician for Mary for many years. Recently,
she sought your advice for tiredness. Mary’s T4, T3RU, and TSH indicate normal thyroid
function. She has a normal thyroid gland by palpation and scan. You advised that the thyroid
was not a cause of her tiredness. Nonetheless, she sought advice from another physician who
runs a weight loss clinic. He advised weekly tests of thyroid function, and thyroid
supplementation. She asks your counsel. You should:

1. Terminate the physician-patient relationship, noting that you cannot provide care for
her if she is consulting another physician.

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 2. Advise her to follow the recommendations of the other physician.

3. Advise her that you see no reason for weekly tests or supplementation, but will
continue as her PCP even if she chooses to take advice from another physician.

4. Report the other physician to the state medical board for unethical practices.

Response: In this case, autonomy mandates that the patient is the ultimate decision-
making authority. Even though you are her nurse, she has the right to seek advice from others.
In a disagreement about appropriate treatment you should acknowledge the diversity of
opinion in medical issues, but reiterate your position that she does not have a thyroid
problem. You should also state that you support her right to obtain second opinions, and your
willingness to continue as her advocate and nurse despite the difference of opinion. An ethical
issue is involved if the other physician is intentionally giving false advice (as opposed to
unintentionally giving bad advice).

B. Confidentiality

Confidentiality is the third element of Respect for Persons. Physicians are expected to
keep confidential what they know about patients. The advent of health insurance, utilization
management, and disease management threaten this element. Patients, by virtue of their
contracts with insurance companies or their use of legal entitlements, have given up some of
their rights in order to get benefits (usually by signing an insurance form). These agreements
allow all diagnoses and clinical information to be shared with insurers, the government,
managed care organizations, and numerous others. However, each organization that receives
information is expected to maintain the confidentiality so that none except those who need
to know are provided with the information.

Situation: Gary is a 13-year-old boy with abdominal pain, diarrhea, night blindness, and
iliac positive stools. You think the symptoms and signs are likely due to inflammatory bowel
disease involving the terminal ileum. You submit to the health plan a request for
preauthorized payment for the patient to have an upper GI endoscopy performed by an out
of network gastroenterologist. The request is denied because the gastroenterologist is out-
of-network. The employer has called stating their support of the patient’s interest, and
requests a periodic update. Your office manager asks whether it is ethical and legal to divulge
patient-specific data to the health plan without the patient’s written consent.

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 Response: Patient-specific information can be divulged only with the patient’s
consent. When the patient signed for health insurance (either directly signing for it or
indirectly choosing the insurance from a menu of plans offered by the employer), the patient
likely agreed to the insurance company being given medical information for the purpose of
utilization review or claims payment. The health plan has a legal right to the medical
information. The patient’s consent, however, is limited to the health plan. You do not have a
legal right, despite good intentions, to divulge the information outside the health plan
network of physicians. Specifically, you do not have the right to divulge information to the
employer. Doing so will place you in medical-legal liability.

C. Justice

Webster defines justice, the fourth principle, as being righteous, impartial, and fair.
Justice is applicable not only to the care of the individual patient, but also in the case of
resource allocation decisions now required daily by Medicaid, Medicare, HMOs, insurers, and
employers.

Equal treatment is also a concept that falls under justice. Justice requires that all
patients with equal health insurance benefit or coverage (or who will pay their own bill) be
offered equal treatment, regardless of the source or amount of payment. Justice does not
require equal treatment if the patients have different benefits or will not pay their bill. Further,
justice does not allow discrimination based on payment. If two patients have similar benefits,
but you have contracted to accept different payments, the two patients have a right to equal
treatment. Justice, in delivery of contracted health care, depends on the benefit, not on the
payment methodology.

Situation: Your medical clinic offers the only diabetes education resources within a 75-
mile radius. The education service has been losing money since the new director you hired
instituted guidelines to insure that all patients receive fair and equal treatment. You discover
that the services are being provided to all patients regardless of their insurance coverage.
Your director says she has an ethical responsibility to treat all patients equally, and that you
have an ethical responsibility to accept the monetary loss incurred by provision of these
services.

Response: Justice requires that you offer necessary services to all patients who require
them. Justice does not require that you deliver the services for free. The director will benefit
from education about the ethical principle of justice.

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D. Autonomy

Autonomy states that each patient should be able to determine his or her own affairs.
However, the basic principle that underlies informed consent states that for patients to
determine their own affairs they must not be coerced. Informed consent requires that
patients be provided with a basic understanding of key issues and information necessary to
govern their own medical decisions. Informed consent is necessary from the standpoint of
medical ethics because ultimately only the patient can give consent to invade the patient’s
body. This principle causes ethical dilemmas when family members, the health care team, or
an insurance company attempt to make decisions that remain the ethical right of the patient.
The issue is complicated by the fact that the patient, by directly or indirectly joining a health
insurance plan, gives up certain rights and agrees to abide by the values of the insurance
company.

Situation: For three days, a patient in previous good health experiences low back pain
without radicular pain following a day of water skiing. She has a friend who had a lumbar
laminectomy for herniated disc, and the patient requests an MRI to rule out disc herniation.
Your assessment is that there is little likelihood that surgery would remedy the situation,
based on the absence of radicular symptoms. Describe the ethical dilemma.

Response: There is a conflict between the physician’s respect for patient autonomy
(which support the patient’s right to make decisions regarding their own welfare) and the
physician’s respect for beneficence, the desire to do only those things beneficial for the
patient. An MRI is likely to show no disc rupture, and thus will not influence the course of
therapy. The issue is complicated by the fact that money not spent on this patient may be
available to cover the cost of care for another patient.

E. Beneficence and Non – Maleficence

Beneficence is acting with charity and kindness. Medical care is intended to benefit the
patient. This requires the physician to do all he/she can to aid the patient. Charity is love of
one’s fellow human being, an act of good will or showing a caring attitude. It is from this
principle that many of the not-for-profit charitable health care organizations were formed.
The mission of charitable institutions requires that charity care be given even when patients
cannot afford to pay for the service. Providing free care in your office is beneficence. Other
acts of beneficence include opening the office for a patient who arrives after hours, providing

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services or advice for a community organization, or providing special services that benefit the
community

Non – maleficence is similar to the Hippocratic Oath, First, do no harm. Physicians are
expected to undertake those actions that are beneficial to the patient and to avoid those that
are harmful to the patient. Though few physicians would disagree with this principle, its
complexity is illustrated by situations where the patient may experience pain or potential
harm from a treatment. The more dangerous or threatening the treatment, the more non-
maleficence plays a role in decision-making.

Situation: Besides his clinical practice, Dr. Johns serves as director of the local blood
bank, for which he receives a fair salary. Because the bank is recognized as an important
community resource, Dr. Johns has benefited from positive publicity, including a newspaper
biography that describes his work for the blood bank as beneficent. Is it?

Response: Beneficence is characterized by kindness and charity. Beneficence is more

a state of mind, and demonstrated over time, rather than by a single act. It does not have to
involve money. Since he has a salaried position, it is difficult to straightforwardly declare Dr.
John’s work for the bank as beneficent. On the other hand, if the work is in addition to his
clinical work, it may cost him more of his most precious commodity: time. The salary may be
incidental. If he has given of his time, especially if it affects his personal life, then one could
make an argument that his work is beneficent. If he later gives the salary to charity, then both
the blood bank work and the cash gift demonstrate beneficence.

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 4. It is essential that nurses should be knowledgeable about principles guiding ethical
conduct whether dealing with academic assignments, research data or research
regarding human and research subjects. What are some academic and research issues
and relate it to ethics.

Ethics is rooted in the ancient Greek philosophical inquiry of moral life. It refers to a
system of principles which can critically change previous considerations about choices and
actions. It is said that ethics is the branch of philosophy which deals with the dynamics of
decision making concerning what is right and wrong. Scientific research work, as all human
activities, is governed by individual, community and social values. Research ethics involve
requirements on daily work, the protection of dignity of subjects and the publication of the
information in the research.

However, when nurses participate in research they have to cope with three value
systems; society; nursing and science. The societal values about human rights, the nursing
culture based on the ethic of caring and the researcher's values about scientific inquiry.
According to Clarke these values may conflict with the values of subjects, communities, and
societies and create tensions and dilemmas in nursing.

Ethical Issues in Conducting Research

A. Informed Consent

Informed consent is the major ethical issue in conducting research. According

to Armiger (1997): "it means that a person knowingly, voluntarily and intelligently, and
in a clear and manifest way, gives his consent".

Informed consent is one of the means by which a patient's right to autonomy

is protected. Beauchamp and Childress define autonomy as the ability for self-
determination in action according to a personal plan. Informed consent seeks to
incorporate the rights of autonomous individuals through self- determination. It also
seeks to prevent assaults on the integrity of the patient and protect personal liberty
and veracity. Of course individuals can make informed decisions in order to participate

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 in research voluntarily only if they have information on the possible risks and benefits
of the research.

Free and informed consent needs to incorporate an introduction to the study

and its purpose as well as an explanation about the selection of the research subjects
and the procedures that will be followed. It is essential to describe any physical harm
or discomfort, any invasion of privacy and any threat to dignity as well as how the
subjects will be compensated in that case. In addition the subjects need to know any
expected benefits either to the subject or to science by gaining new knowledge.

Ethical issues, conflicting values, and ambiguity in decision making, are

recurrently emerging from literature review on nursing research. Because of lack of
clarity in ethical standards, nurses must develop an awareness of these issues and an
effective framework to deal with problems involving human rights.

Moreover, the subject must be told that some information has been
deliberately withheld in order to avoid altered behaviors. The researcher must also
take into account that persons with physical, cultural and emotional barriers may
require a very simple language in order to understand him. Finally, the freedom to
withdraw must be explained. This is very important but raises the issue of how difficult
the subjects can withdraw after developing a personal and sometimes friendly
relationship with the researcher.

B. Beneficence and Non – Maleficence

Beneficence is sometimes difficult to predict when creating a hypothesis

especially in qualitative research. Non-maleficence requires a high level of sensitivity
from the researcher about what constitutes "harm". According to Burns and Grove
"discomfort and harm can be physiological, emotional, social and economic in nature".

When a researcher tries to learn intimate details of the participants lives he has
to deal with opening old wounds. Non-maleficence dictates both preventing
intentional harm and minimizing potential harm. A researcher must consider all
possible consequences of the research and balance the risks with proportionate
benefit. The type, degree, and number of potential risks must be assessed as well as
the patient’s value system which ranks various harms. The risk benefit ratio can only
be achieved by identifying these factors. If the risks outweigh the benefits, the study
should be revised.

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 Last, debriefing at the end of a study, should be mentioned. It refers to
explaining the exact aim of the study and why the disclosure was not full. It is
suggested that subjects should feel as much at ease as possible and express their
feelings. In addition, if the subjects experienced a high level of discomfort, they should
be debriefed or referred to appropriate professional intervention as necessary.

C. Respect for Anonymity and Confidentiality

The issue of confidentiality and anonymity is closely connected with the rights
of beneficence, respect for the dignity and fidelity. ANA suggests anonymity is
protected when the subject's identity cannot be linked with personal responses. If the
researcher is not able to promise anonymity he has to address confidentiality, which is
the management of private information by the researcher in order to protect the
subject's identity. The researcher is responsible to "maintain confidentiality that goes
beyond ordinary loyalty".

According to the utilitarian theory, which focuses on the best interest of all
involved, the happiness of society is of greater importance. On the other hand, the
deontological theory which ignores the result implies that the moral duty is what really
matters. If a researcher, though, acts deontological he may feel that he has not
protected society. Another issue is that the researcher may have to report confidential
information to courts which can also cause moral dilemmas. In that cases it can be
argued that the moral duty and personal ethos can be stronger than legal
requirements. Even if there are no duty conflicts, the researcher faces several
problems with respect to maintaining confidentiality especially in qualitative research
where conduct is personal, the sample is smaller and the reports display quotations of
interviews.

The researchers must always bear in mind all psychological and social
implications that a breach of confidentiality may have on subjects. In order to protect
participants, they have to inform them on their rights, and use all possible coding
systems that they regard appropriate in each case.

Ethical issues, conflicting values, and ambiguity in decision making, are recurrently
emerging from literature review on nursing research. Because of lack of clarity in ethical
standards, nurses must develop an awareness of these issues and an effective framework to

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deal with problems involving human rights. This is necessary in order to come into terms with
the issue of the researcher's values relative to the individual's rights versus the interests of
society. Professional codes, laws, regulations, and ethics committees can provide some
guidance but the final determinant of how research is performed, rests with the researcher's
value system and moral code.

To prepare future nurses, ethics in research, must receive special attention in nursing
curricula. The criticism and uncertainties that arise, should be rather encouraged than
suppressed in nursing education. Hunt suggests that in order to liberate nursing from its
"technocratic impasse" ethics should be broadly interpreted as an arena of new ideas which
can change professional hierarchies, to open cross-disciplinary discussions, and question the
concepts "abnormality", "patient" and " illness". He also declares that nursing, not as a
biomedical branch, but as a science and art of caring, is able to start the redefinition of
research in health care which was in the recent history dominated by the biomedical
"paradigm".

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 5. Below are problem areas regarding ethics, choose 5 among the list below and
discuss each relating to ethical competence :

A. Documentation
B. Staffing issues
C. Clinical Practice Guidelines
D. HIV Client’s and health works
E. Professional relationship
F. Health information management
G. Scholarship issues
H. Others

1. Documentation

Nursing documentation is a vital component of ethical, effective and safe

nursing practice, regardless of the context of practice or whether the documentation
is paper-based or electronic. The nurse’s documentation may be used as evidence in
legal proceedings such as lawsuits, autopsy’s reports, and disciplinary hearings
through professional regulatory bodies. The intention of the document is to assist the
registered nurse to meet their standards of practice related to documentation.
Nursing care and the documentation of that care will be measured according to the
standard of a reasonable and prudent nurse with similar education and experience in
a similar situation.

2. Staffing Issues

Nurse staffing appear to be merely the top of ethical issues. The subservient
position of clinical nurses seems the underlying root cause of nurse staffing problems.
Below the surface three underlying main themes became clear; nursing behavior,
authority, and autonomy, cross-cut by a single overall theme; nurses’ position. Ethics
has to do with trying to determine “what is the right thing to do in a given situation”.
A synthesis of the research on nurse staffing and patient outcomes indicates that:

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 • Ratios of RNs to patients are important. Consensus seems to be emerging
supporting a staffing ratio range between 4 and 6 patients per nurse in most
hospital inpatient settings; and a range between 1 and 2 patients per nurse
in critical care settings. However, ratios should be modified by the nurses’
level of experience, the patients’ characteristics, and the practice
environment.

• High quality and frequent clinical interaction among RNs and MDs is
important to safe care.

• There is increasing evidence that turnover and fatigue, as well as high

patient load, contribute to errors, recidivism, length of stay, and costs.

• Especially since the advent of mandatory staffing ratios, there has been
increasing evidence of the importance of maintaining adequate support
staff for nurses.

In general, nurses’ behavior, way of thinking, decision-making, and

communicating thoughts or information differs from other disciplines like physicians.
This results in a perceived and actual lack of authority and autonomy. We have the
data. We know we put patients at risk if we do not staff according to the data. The
ethical conversation is over. This in turn hinders them to plead for adequate nurse
staffing in order to achieve the common goal of safe and high-quality patient care.

3. HIV Client’s And Health Workers

Ethics of Medical Confidentiality: The nurse is ethically bound to protect the

patient from harm to the best of your ability according to your training, guidelines, and
protocols. For example, if you know that a patient is allergic to sulfa drugs and have an
order to give them co-trimoxazole, you are ethically bound to prevent harm (an allergic
reaction caused by giving that patient the drug) and ensure the patient does not
receive a sulfa-based drug. Patients are also harmed by stigma and discrimination by
healthcare workers. – Stigma and discrimination experienced by patients in the
healthcare setting cause harm to patients; negative experiences with healthcare
workers delay and/or prevent patients from seeking essential healthcare in the future.
Your role is to help the patient obtain care and treatment for HIV-related conditions
including providing direct care and referrals for services provided outside your
clinic/facility.

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 Duties to patients: The ethical implications are more complex, however, if the
person at risk is not a patient of the same doctor, or if the person at risk might have
reason to suspect that their sexual partner is infected. In the latter case, the patient at
risk may appear unaware of what the doctor would consider reasonable grounds for
uncertainty about whether or not their potential partner is infected - for example, that
they either have had other sexual partners, or have previously contracted a sexually
transmitted disease. Since these may still be popularly regarded as less risky forms of
behavior than, for example, needle-sharing, it might be argued that in this case the
doctor does have a duty to breach confidentiality, in order to protect the at-risk
patient. There are strong reasons for resisting this argument. What the doctor may
consider as a duty, the General Medical Council states, is 'to seek to ensure that any
sexual partner is informed, in order to safeguard such persons from a possible fatal
infection'. His first duty therefore is to make every effort to ensure that his patient
becomes informed of the facts of HIV transmission.

Duties to others: What if the person at risk is not the doctor's patient? In this
case, the doctor has no ready way, without serious risk of breaching confidentiality,
either of discovering if the person at risk is sufficiently informed of the general risks of
HIV infection to make an informed choice about intercourse with the infected patient,
or of ensuring that this information is acquired by them. Here again, a crucial aspect of
the doctor's decision must be his judgement of how far, by maintaining confidentiality,
he can encourage his patient to respect others' interests. In this case moreover, the
doctor cannot tell whether the specific individual whom he suspects to be at risk is the
only person at risk from his HIV-positive patient. He may quite reasonably decide,
therefore, that the most effective way available to him of protecting everyone at risk
is by what he hopes to achieve from maintaining confidentiality.

If the medical profession is seen to accept the general principles on which this
argument is based, we believe, it will help patients to understand that the ground rules
of medical confidentiality, although complex, are consistent and justifiable. If patients
have confidence in these ground-rules, moreover, this will encourage the kind of open
dialogue and mutual empowerment which makes any need for breaches of
confidentiality less likely

4. Professional Relationships

The Nurse should confront any ethical challenge; consult the hospital ethics
committee for decision-making. Cooperate with medical team members, the client /

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 patient and their family, for more efficient presentation of nursing interventions.
Contribute the client / patient or legal guardian in making decision about nursing
interventions. Share his/her professional knowledge and experience with other
colleagues. Establish a good relation based on mutual trust, with medical team. Have
a respectable conduct with other nurses, professors and students. In case of any
conflict of interest in the care of the client / patient, discuss it with senior colleagues
and the principals, while giving the priority to preserving the clients / patients’ rights.
Establish a respectful professional relationship with co-workers in various levels,
including the head nurse, supervisor, nursing director and department heads

5. Health Information Management

As in all other areas of healthcare, ethical issues arise in the management of

health information. Common ethical dilemmas within the field of nursing health
information management include the confidentiality and privacy of medical records,
includes information security on portal devices such as cellphones, tablets and laptops.
Principles of privacy, the patient's right to autonomy and decision-making in the
management of their health information, and concepts of fairness and equity in access
to care and to information are just some examples of areas in which ethics can inform
the nurses’ strategies and decisions.

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 6. Discuss at least 10 Bioethical issues and concern related to ethics as a professional
nurse:

1. Cloning

Cloning can occur at the level of DNA, at the level of the single cell, or at the
level of the whole organism. Typically, ethical attention is focused upon cloning in the
context of the genetic copying of a whole organism. While the cloning of non-
mammals has occurred in research contexts for many years, the cloning of the first
mammal, Dolly the sheep, surprised many in the scientific community. What quickly
followed was the cloning of other species and intense speculation about the possible
cloning of humans. Cloned human embryos have been produced, but there are no
reliable reports that any have been implanted in a woman’s uterus, let alone developed
to birth. Cloning to birth has come to be called ‘reproductive cloning’, whereas cloning
embryos so that their stem cells may be extracted for possible research or therapeutic
use has come to be called ‘therapeutic cloning’. The key ethical issue with therapeutic
cloning is the moral status of the cloned embryo, which is created solely for
destruction. The ethical issues with reproductive cloning include genetic damage to
the clone, health risks to the mother, very low success rate meaning loss of large
numbers of embryos and fetuses, psychological harm to the clone, complex altered
familial relationships, and commodification of human life.

2. Consent

Obtaining consent from a patient prior to treatment or from a research subject

is a relatively new concept. In the late 18th century, Benjamin Rush told doctors to
“yield to patients in matters of little consequence, but maintain an inflexible authority
over them in matters that are essential to life”. In subsequent years the concept of
informed consent grew rapidly to take on the relatively well-developed form it now
has. Even so, obtaining genuine informed consent in practice often falls short of
displaying respect for the decision-making capacity of the patient or research
subject. This is the primary idea behind the requirement for informed consent, that is,

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 the basic ethical principle that persons are owed respect for making their own
autonomous decisions. For informed consent to be adequately served the person
must be provided with all of the relevant information in the appropriate context. Not
only can consent be tricky in clinical practice, but when it comes to research there may
be ethically justifiable circumstances in which consent may be waived. Furthermore,
consent can take on even more complex characteristics when it is expressed in an
advanced form such as in a medical advance directive, or in organ donation after death.

3. Genetics

There was a pivotal moment that took place in the early 1950s, which has given
rise to the burgeoning field of molecular genetics. In 1952, two now famous Nobel
Laureates, Francis Crick and James Watson, discovered the molecular structure of DNA
(a double helix) and confirmed that DNA was indeed the genetic material. Now the
race is on to decode the genetic information, to discover the genetic basis of all our
human traits, and to use genetics to reveal our phylogenetic relationships. What is
more exciting and controversial is the possibility of manipulating our genes so as to
restore damaged health or even enhance many of our biological functions. However,
as is the case with any scientific and technological developments, there are whole host
of ethical problems that must be considered. The possibility of manipulating our genes
in order to enhance our biological, as well as psychological nature, is hugely
problematic. It is foreseeable that it may lead to a new eugenics, and a radically
undesirable change in our human nature. There are also other ethical issues relating to
genetic information and the implications of having such information, for example,
genetic discrimination and the ethics of genetic screening.

4. Euthanasia

Euthanasia is the intentional and painless taking of the life of another person,
by act or omission, for compassionate motives. The word euthanasia is derived from
the Ancient Greek language and can be literally interpreted as ‘good death.’ Despite
its etymology, the question whether or not euthanasia is in fact a ‘good death’ is highly
controversial. Correct terminology in debates about euthanasia is crucial. Euthanasia
may be performed by act or omission - either by administering a legal drug or by
withdrawing basic health care which normally sustains life (such as food, water or
antibiotics). The term euthanasia mostly refers to the taking of human life on request

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 of that person – the euthanasia is voluntary. However, euthanasia may also occur
without the request of person who subsequently – euthanasia is non-
voluntary. Involuntary euthanasia refers to the taking of a person’s life against that
person’s expressed wish/direction.

Central to discussion on euthanasia is the notion of intention. While death may

be caused by an action or omission of medical staff during treatment in hospital,
euthanasia only occurs if death was intended. For example, if a doctor provides a dying
patient extra morphine with the intention of relieving pain but knowing that his
actions may hasten death, he has not performed euthanasia unless his intention was
to cause death (Principle of Double Effect). Euthanasia may be distinguished from a
practice called physician-assisted suicide, which occurs when death is brought about by
the persons own hand (by means provided to him or her by another person). All
practices of euthanasia and physician-assisted suicide are illegal in Australia.

5. Moral Agency

What distinguishes humans from other animals is that we use reason and
reflect on our beliefs, values, expectations and experiences, to make important
judgments and decisions - we are rational. In the absence of such capacities we cannot
be held responsible for our decisions and actions - we would no longer be moral
agents. Recent evidence from the sciences of the mind, particularly cognitive
neuroscience, suggests that we may not be as morally rational as we thought. This
raises questions about the scientific and theoretical foundations of moral agency,
which will therefore clearly have normative implications. Will this change the way we
think of ourselves as persons and moral agents? The neuroscientific data has also
refueled some debates central in moral philosophy, particularly meta-ethics. How does
neuroscientific data bear on these topics, and can it inform those philosophical
debates?

Neurological dysfunction is generally held to be relevant to a defendant’s

responsibility for their actions. Hence when diminished responsibility can be
established by appeal to neurological dysfunction (“neuro-mitigation”), then it is
reasonable that the defendant receives a proportionate punishment. However, the
challenge of imputing responsibility is difficult given the multitude of the deterministic
effects of brain function, genetic predispositions, experience and environment. Hence
one ought to ask whether cognitive neuroscience, amongst other sciences of the

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 mind, will have a bearing on the legal doctrine of mens rae and thus change our
perception of legal responsibility?

6. Neonatal Ethics

Neonates are babies within their first twenty-eight days of life. Neonatal
intensive care often caters for babies in one of three groups – premature babies with
low birth weight, full-term babies born with acute conditions or babies born with
congenital anomalies.

Ethical issues mostly surround decision making on behalf of neonates.

Decisions involve the weighing up of treatment that is beneficial or futile, considering
the individual’s short-term and long-term prognosis. Two main issues in the decision
making process are the chance of surviving medical intervention and future quality of
life.

The most famous case of neonatal decision-making involved Baby Doe. In 1982,
Baby Doe was born with Down’s syndrome and a tracheal-esophageal fistula. The
parents chose not to consent to the baby having the fistula repaired in surgery, based
on the child’s best interests and lack of quality of life associated with Down’s
syndrome. Baby Doe eventually died of starvation.

Treatment may be obligatory, optional or futile. It is often the case when the
prognosis of a newborn looks good, that the parents and physicians agree to treat
accordingly. However, occasionally parents do not want their newborn to be treated,
and in these circumstances hospital ethicists are sometimes required to seek a court
order to override the parent's decision and initiate treatment. It is more controversial
when the prognosis of a neonate is unknown, and the parents with the physician are
given the opportunity to discuss whether to treat or not. Bioethics addresses the
parameters and obligations of those involved in the decision-making. Finally, there are
cases when treatment is considered futile, yet the physician or the parents insist on
treatment. Treatment in these situations is considered extremely burdensome and
experimental and the chance of surviving treatment with any quality of life is small.
Patient rights, parental rights and the duty of the physician are all considered in a
bioethics evaluation.

Technology and medical interventions in the neonatal intensive care unit have
developed at a steady pace over the past 40 years, and with this development there

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 have been joyful stories of recovery but also saddening stories of severe disability.
Bioethics can assist by addressing questions related to the regulation on use of
experimental technological developments and by providing guidance in controversial
situations.

7. Reproductive Technology

Assisted reproductive technology (ART) is a medical intervention developed to

improve an ‘infertile’ couple’s chance of pregnancy. ‘Infertility’ is clinically accepted as
the inability to conceive after 12 months of actively trying to conceive. The means of
ART involves separating procreation from sexual intercourse - the importance of this
association is addressed in bioethics.

Some techniques used in clinical ART include: artificial insemination; in vitro

fertilization (IVF); gamete intra-fallopian transfer (GIFT); gestational surrogate
mothering; gamete donation; sex selection and pre-implantation genetic
diagnosis. Issues addressed in bioethics are the appropriate use of these technologies
and the techniques employed to carry out procedures for quality and ethical reviews.

Assisted reproductive technology and its use directly impact the foundational
unit of society – the family. ART enables children to be conceived who have no genetic
relationship to one or both of their parents. Children can also be conceived who will
never have a social relationship with one or both of their genetic parents, e.g. a child
conceived using donor sperm. Non-infertile people in today’s society including both
male and female homosexual couples, single men and women, and post-menopausal
women are seeking the assistance of ART. Concerns in all situations include the child
and his or her welfare, including the right to have one biological mother and father.
The fragmented family created by ART can disconnect genetic, gestational and social
child-parent relationships which have typically been one and the same in the traditional
nuclear family.

Other important bioethical issues include the appropriate use of pre-

implantation genetic diagnostic screening, use, storage and destruction of excess IVF
embryos, and research involving embryos. ART research requires human participants,
donors and donated embryos, oocytes and sperm.

Ethical issues that arise in ART research surround the creation and destruction
of embryos. One approach in bioethics involves preserving justice, beneficence, non-

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 maleficence and the autonomous interests of all involved. Bioethicists contribute to
ethical guidelines and moral evaluations of new technologies and techniques in ART as
well as to public discourse that leads to development of national regulations and
restrictions of unacceptable practices.

8. Research Ethics

Research involving people, their data or tissue, requires proper ethical conduct
that respects them and demonstrates responsible conduct which reflects a genuine
concern for their betterment and that of the community.

The values of ethical conduct in research include respect for human beings,
justice, beneficence, research merit and integrity. Respecting human beings, by
recognizing everyone’s inherent value and human dignity, ought to govern
interactions with research participants. Doing so shows respect for autonomous
individuals (who have the capacity to make decisions and determine their own life) and
to protect those who are vulnerable and unable to express their autonomy. Justice
recognizes human equality, which involves fairly distributing the benefits and burdens
of research and treating all participants fairly. Beneficence in research involves the
consideration and awareness of possible harms and benefits to the participants and
their community.

Merit and integrity in research is essential for any research to be ethically

justified – research must show that it is a potential benefit to the community by
improving understanding or knowledge, that the research is well designed to achieve
the proposed aims, is conducted honestly and respectfully, and upholds fundamental
medical research principles.

Ethical research must always identify, gauge and minimize any risks that pose a
threat to participants and their communities. Risks may be managed or justified by the
potential benefit of the research.

Voluntary, non-coerced consent is required, based on a person’s autonomous

capacity to be involved in research. This demonstrates that they have made a voluntary
choice based on understanding information regarding the study. Some studies may
involve participants unable to provide informed consent. These special cases include
pregnant women and the human fetus in utero or ex utero, embryos, children and
some disabled people. Guidelines for ethical considerations specific to participants can

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 be found in the National Statement on Ethical Conduct in Human Research 2007
(NHMRC).

9. Surrogacy

It is often a devastating and life changing experience for a woman to discover

that for one reason or another she cannot become pregnant and have children of her
own. In some cases, such as those involving repeated unsuccessful attempts involving
assisted reproductive technology (ART) or having a non-functional uterus, the
remaining option (besides that of adoption) for these women and their partners is
surrogacy. However, a major concern with surrogacy is the potential harm that may be
inflicted upon the surrogate mother and the child. There are a number of ethical issues
relevant to this topic. The ideals and values we hold concerning liberty and autonomy,
have to be weighed against other values such as informed consent, welfare and
exploitation. Surrogacy, when occurring in the context of ART, is also an issue that
forces us to reassess many concepts such as parenthood, family structure and best
interests, which until the recent surge in the popularity of surrogacy, we took for
granted.

10. Transgenic and Xenotransplantation

Advances in technology have made it possible for human and animal biological
material to be mixed in a permanent way. Xenotransplantation refers to the
transplantation of animal tissues and organs into human recipients, either without or
with genetic modification of the animal to minimize tissue rejection. Transgenic refers
to the mixing of human and animal genes. For example, human genes can be
introduced into sheep so that certain valuable human proteins will be expressed in the
sheep’s milk. Another variant of human/animal mixing has recently occurred in the
context of stem cell research. Researchers have introduced the human nuclear
genome into enucleated eggs of cows, pigs and rabbits to produce a cloned
human/animal hybrid, termed a cybrid. There is no intention to implant any of the
embryos for further development. Human and animal cells can also be mixed in the
early embryo to produce a chimera.

Important ethical questions arise about such mixing and some of the concerns
center on safety issues. Will the introduction of animal tissues into humans lead to

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 new viral outbreaks? Other complex ethical questions surround the question of
human dignity and whether it is an affront to human dignity for such intimate mixing
of human and animal biological material to occur. And whether there are issues with
some techniques that do not apply to others?

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