Ethics and Legalities in

Nursing
BY
Himali prajapati
Assistant Professor
Child health nursing
C.M Patel college of nursing

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

Foundation
Ethics philosophical ideals of right and
wrong behavior.
Ethics is not religion or law
Nurses have a duty to practice ethically
and morally
Tells us how human beings should behave,
not necessarily what they do. Not a
religion, not law, but both of these can be
the basis of ethical decisions that you
make.
The word duty is a legal term

Ethical Issues
Moral uncertainty/conflict
When the nurse is unsure which moral principle to apply,
or even what the problem is. Common with new nurses,
theyre not sure what they are supposed to be doing

Moral distress
When the individual knows the right thing to do but
organizational constraints keep them from doing it

Moral outrage
An individual witnesses an immoral act by another but
feels powerless to stop it

Moral/ethical dilemma
Occurs when two or more clear principles apply but they
support inconsistent courses of action

Self-awareness
Not an ethical issue, but is absolutely vital in ethical
decision making

Ethical Frameworks
Utilitarian most good, least harm
Most common approach, First do no harm is related to this.
Attempts to produce the greatest good with the least harm.

Rights based best protects the rights and respects

the moral rights of those affected
Begins with idea of human dignity and freedom of choice.
The pt has the right to make the decision.

Duty based- duty to do or to refrain from doing

something
Decisions are made because there is duty!

Common good best for community/society

Decisions should be made on what is good for the
community as a whole, not necessarily for the individual.
Where many of our nations laws are base

Virtue actions consistent with certain ideal virtues

Decisions should be directed at maintaining virtues (honesty,
courage, compassion, etc.). A person using this approach
may ask themselves, If I carry out these actions, what kind
of person will I be?

Principles Ethical
Reasoning

Autonomy
Beneficence
Nonmaleficence
Confidentiality
Double Effect
Fidelity
Justice

Paternalism
Respect for Persons
Sanctity of Life
Veracity

Autonomy
Definition: autos = self, nomos = rule
Individual rights
Privacy
Freedom of choice
Pt has the right to make decisions for
themselves. May see this come up with
consent for treatment issues, informed
consent. Pt has right to know procedure,
complications, other options, that they can
opt to not have the procedure/treatment.
Framework is rights based

Beneficence &
Nonmaleficence
Duty to do good
goodness, kindness,
charity

Includes
nonmaleficence
Centerpiece for
caring

Duty: NOT TO CAUSE

harm
Duty: PREVENT harm
Duty: REMOVE harm
More binding than
beneficence
Because youre going
beyond just trying to
do good to that pt,
youre trying to
prevent harm

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

HIPAA

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

Fidelity
Duty to be faithful to ones commitments
includes implicit and explicit promises
Make a promise, follow thru

Implicit those promises that are

implied, not verbally communicated
Like when pt comes into the hospital, they
expect to be cared for

Explicit those that we verbally

communicate
Like if you tell them youll be back with pain
meds, youd better come back

Justice
Seeks fairness Distributive Justice
Concepts
More
Equally disbursed
specifically,
according to
distributive
Need
justice refers
Effort
to distribution
Societal
of benefits
contribution
and burdens

Merit
Legal entitlement

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

Respect for Persons

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

Sanctity of Life
Life is the highest good
All forms of life, including mere
biologic existence, should take
precedence over external criteria for
judging quality of life
If life is the highest good, is it ethical
to keep a brain dead person alive?

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

Ethics and Professional

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

Euthanasia
Assisted suicide
Death
Disasters

American Nurses Association

(ANA) Code of Ethics
Applies to all nurses in all
healthcare settings
Ethical principles agreed upon by
members of the nursing profession
Sets standards of conduct and
behaviors for nurses
http://www.nursingworld.org/mainmenucategori
es/ethicsstandards/codeofethicsfornurses

ANA Code of Ethics Key

Points

Applies in course of professional

practice:

Primary commitment is to patient (individual,

family or community)
Demonstrates compassion and respect for all
patients regardless of patient status
Promotes the health and welfare of patients
Accountable for individual practice.
Maintains and increases own knowledge base
Works to improve healthcare environment for
providers and patients

ICN Code of Ethics

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

Nurses Rights in Ethical

Situations
Nurse has the right to refuse to
participate in giving care to a client if
they disagree with care on ethical
grounds.
Upheld by ANA
Assure client is not abandoned for care
The Joint Commission (TJC) requires
employers to establish policies and
mechanisms to address staff requests not to
participate in aspects of care that conflict
with cultural values or religious beliefs.

Nursing Practice
Regulations

TBON Texas Board of Nursing

Regulates nursing practice in Texas

Creates Rules and Regulations to
administer the Nurse Practice Act (NPA)
Describes rules of conduct for nurses
Rule 213.27 Good Professional Character
Rule 217.11 Standards of Practice
Rule 217.12 Unprofessional Conduct

http://info.sos.state.tx.us/pls/pub/read
tac$ext.ViewTAC?tac_view=3&ti=22&pt=11

NCSBN Professional
Boundaries
Concepts of Professional Boundaries
Boundaries: Space between nurses
power and clients vulnerability

Crossings: Brief excursions across

boundaries that may be inadvertent,
thoughtless, or even purposeful if done to
meet a specific therapeutic need
https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf

NCSBN Professional
Boundaries
Concepts of Professional Boundaries
Violations: results when there is confusion
between the needs of the nurse and those of
the client.

Sexual misconduct: extreme form of

violation that is seductive, sexually
demeaning, harassing or interpreted as
sexual by the client.
https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf

Identifying Boundary
Crossings

Excessive self-disclosure

When the nurse discusses personal feelings or

aspects of their personal life in front of the pt

Secretive behavior
When the nurse keeps secrets with the client or
when the nurse becomes guarded when someone
questions their interactions

super nurse
When the nurse believes only he or she can meet
the needs of the client

Selective communication
When the nurse fails to explain actions or actions
of care

Identifying Boundary
Crossings
Singled out client treatment/client
attention to the nurse
Nurse spends inappropriate amts of time with
the client, client may give gifts to the nurse

Flirtations
Never, ever, appropriate, or ok, ever, ever

You and me against the world behavior

Nurse views client in a protective manner

Failure to protect the client

Nurse doesnt recognize sexual feelings
towards the client

Nurses Challenge
Be aware
Be cognizant of feelings and behaviors
Be observant of the behavior of other
professionals
Always act in the best interest of the
client

https://www.ncsbn.org/Professional_Boundaries_2007_Web.pdf

Informed Consent

Core underlying value is patient autonomy

Physician / practitioner obtains consent
Nurses role: witness / monitor
Emergency consent is presumed when
patient unable to provide
Informed consent is a process that people
go thru, not just a paper.
Nurses role is to make sure pt understands
everything and that the person that signs is
the person who needs to be signing! The
nurse cant go in and explain the procedure
again, if you contradict what the doc told
the pt, youre in big trouble! Dont do it!

Capacity to Form
Consent

Decision-making capacity (not

competency) determined by:

Appreciation of right to make the choice

Understanding of risks/benefits of
procedure
Understanding of risks/benefits of opting
out of procedure
Ability to communicate decision
Communication may not always be verbal, can
be written or whatever
Needs to have interpreter avl! Cant just use
the family or whatever
Use layman jargon. Normal words Dont say
layman jargon.

Advance Directives
Include

Directive to Physician and Family or Surrogate

Most common. Allows pt to document wishes for tx or withdrawal,

also commonly known as Living Will

Medical Power of Attorney

Allows the pt to designate another person as their decision maker

Out of Hospital Do-Not-Resuscitate Order

Allows competent adults to refuse life sustaining procedures when

out of the hospital setting. Can include not wanting to be taken to
ER, let me sit here and die

Declaration of Mental Health Treatment

Allows a court to determine incapacity and allows the pt to refuse

electro convulsive therapy (ECT) and psychoactive drugs

Sometime generically called Living Will

Not same as DNR (do not resuscitate)

These are written during hospitalization after the doc and the
pt (or pt surrogate) decide to withdrawal life sustaining
treatments.

Advanced Directives are documents that state in

writing the pts wishes for healthcare interventions if
they should become incapacitated.

Other Contingencies
Directives unavailable / never done
Autonomy versus best interest of clients
Substituted judgment
Legal standard that presumes the surrogate is
capable of making decisions for that pt

Dementia clients
Dementia diagnosis doesnt necessarily mean
the pt is incapable of making their own
decisions. Esp in the first few stages of
dementia. Pt is very alert and very aware and
very much can make that decision for
themselves.

Withholding/Withdrawing
Care
Can withhold inhumane treatment if
it is virtually futile in extending life
usually DNR
Allowing to die vs making die

Euthanasia
Definition intentional termination of life (at the
request of that person who wishes to die)
Active vs. Passive

Generally illegal
May be legal under certain circumstances
Active involves purposefully causing the persons
death (doc or nurse). Dr. Kevorkian. Usually involved
with law problems
Passive involves hastening of death by altering
some form of support, taking a pt off a vent, generally
accepted by medical community

Terminal sedation

Doctrine of Double Effect (the whole intent of the act,

thing)
Do a thing with one intent, but causes something else
to happen morphine OD
Procedure used in dying pts to relieve suffering. Pts
who are in extreme pain may chose terminal sedation

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

Defining Death
Uniform Determination of Death Act
patient is dead if any one of the
following conditions are met:
Cardiopulmonary death
Neurological death
Whole brain death Flat EEG
Not PVS (persistent vegetative state)

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

How to Process an Ethical

Dilemma
1. Determine whether or not a dilemma
exists
2. Gather all relevant information
3. Reflect on your values on the issues
4. Verbalize problem
5. Consider all possible courses of action
including referral to ethics committee
6. Negotiate outcome
7. Evaluate action, not the outcome.

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

Excerpts: ANA Code of

Ethics
The nurse, in all professional
relationships, practices with
compassion and respect for the
inherent dignity, worth, and
uniqueness of every individual,
unrestricted by considerations of
social or economic status, personal
attributes, or the nature of health
problems.

Excerpts (contd)
The nurses primary commitment is
to the patient, whether an
individual, family, group, or
community.
The nurse promotes, advocates for,
and strives to protect the health,
safety, and rights of the patient.

Excerpts (contd)
The nurse is responsible and
accountable for individual
nursing practice; and determines
the appropriate delegation of
tasks consistent with the nurses
obligation to provide optimum
patient care.

Excerpts (contd)
The nurse owes the same duties
to self as to others, including the
responsibility to preserve
integrity and safety, to maintain
competence, and to continue
personal and professional
growth.

Excerpts (contd)
The nurse participates in
establishing, maintaining, and
improving health care environments
and conditions of employment
conductive to the provision of
quality health care and consistent
with the values of the profession
through individual and collective
action.

Nursing Legalities

Alicia Anger, MSN, RN

N-401
Fall 2010
44

Learning Outcomes
Describe sources of law that
affect nursing practice
Professional negligence
Avoiding Malpractice claims
Causes for
suspension/revocation of license
Legal responsibilities of Nurse
Leaders
45

Distinction between Law

and Ethics
Concepts
Source
Concerns

Law
External
Conduct and
Actions

Interests
Society
Enforcement Courts, BON
s

Ethics
Internal
Motive,
attitude,
culture
Individual
Ethics
Committee
and
professional
organizations

What is law?
Law
Rules of conduct
Authored & enforced by formal authorities
Hold people Accountable for compliance

Purpose of Nursing Law

Protect patient and nurse
Scope of practice (define it)
47

Sources of Law
Constitution: establishes a basis for a
governing system (highest law that gives
authority to the other branches)
Statutes: laws that govern
Administrative agencies: given
authority to create rules and regulations to
enforce statutes (like texas board of
nursing)
Court decisions: interpret statutes and
determine consequences

Types of Court Cases & Laws

Criminal law: crimes committed against an
individual or society, innocent until proven guilty
beyond a reasonable doubt. Consequences range
from fine to jail to death penalty

Civil law: one individual sues another for money b/c

of a perceived loss. Guilty verdict is based on the
belief that the accused is more likely than not to have
caused the injuries. Consequence is usually $$

Administrative law: individual is sued by a

state/federal agency responsible for enforcing
statutes. Based on a clear and convincing standard.
49

Professional Negligence
Negligence: the omission to do something that a
reasonable and prudent person in a reasonable situation would
or would not do

Prudent:

the average judgment, foresight, intelligence

and skill expected of a person of similar training or experience

Malpractice:

failure of a person with professional

training to act in a reasonable and prudent manner

50

Professional Negligence
Five components necessary for
professional negligence to occur:
1. Standard of care
2. Failure to meet standard
3. Foreseeability of harm
4. Correlation b/t care and harm must be proven
5. Actual patient injury must occur
51

Professional Negligence
Reducing the Risk:
Know the law
Document everything
Refrain from negative comments
Question authority
Stay educated
http://www.nurseweek.com/features/00-05/malpract.html

Professional Negligence
Reducing the Risk cont.:
Manage risks
Dont hurry through discharge
Be discreet
Use restraints wisely
Be kind
http://www.nurseweek.com/features/00-05/malpract.html

Liability
Liable: to be legally responsible by
law
Personal liability: every person is
liable for his/her own conduct
Joint liability: nurse, physician, and
employing organization are liable
Respondeat superior liability: the
master is responsible for the acts of his
servants
54

Claims Against Nurses

Inadequate charting.
Inadequate communication w/ HCP or
supervisors about changes in pt
condition
Leaving potentially harmful items
within patient reach
55

Claims Against Nurses

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

56

Incident Reports
Incident reports cant be used in court, unless they
(lawyers and what not) find out that it exists. They are
intended for internal shit only, within the hospital,
monitoring trends, prevention of future occurrences,
etc.
Dont put them in the chart! You can document the
fall, what you did to make it better, but not that you
filled out the actual incident report form.
Dont tell the pt or family that youre filling one out!
Youre not keeping them from any information about
the incident, youre just not telling them about the
form
Dont document on pts chart that you filled one out!
Notify nurse management teams and what not when
you fill it out.
Remember, there is no law about having to fill out an
incident report. Its just the hospitals policy to keep
tabs on all the shit that goes wrong inside its walls

Incident Reports
Unusual / unexpected incidents
Do
Document incident information, treatment &
follow up on chart
Notify Nsg Management & Risk Management
DO NOT
Leave copy on chart
Discuss with pt / family
Document form completion in chart
58

Intentional Torts
Assault & Battery
Assault is the behavior that makes a person fearful
of harm
Battery is an intentional physical contact with a
person that causes injury

False Imprisonment
Any unlawful confinement within fixed boundaries,
can be physical, emotional, or chemical

Defamation of character (slander)

Communicating to a 3rd party information that can
hurt character, self esteem, blah blah blah. Being
truthful reduces risks of being charged with this

Invasion of privacy

59

Types of Consent
Informed consent
Implied consent
Pt unable to consent
Treatment is in patients best interest

Express consent
Witness pt signature
Assure pt received information
60

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

61

Medical Records
Although the patient owns the
information in the medical record, the
actual record belongs to the facility that
originally made record & is storing it

62

Causes of License
Suspension
Professional negligence
Practicing nursing w/o a license
Obtain license by fraud
Felony convictions
63

Causes of License
Suspension
Not reporting substandard medical or
nursing care
Providing patient care under the
influence of drugs/alcohol
Giving narcotics w/o order
Falsely portraying self to public or any
HCP as a nurse
64

Legal Responsibilities
of a Nurse Leader

65

Legal Responsibilities
of the Nurse Leader
Reporting dangerous understaffing
Texas passed law saying you have to have rules
and policies set up and in place in case staffing
issues arise

Ensuring staff credentials and qualifications

Quality Control of nursing practice
Equipment operation by staff
Reporting substandard care
Responsibility to be fair and
nondiscriminatory
66

Malpractice for Nurse

Leader
Assignments
Pt assignments

Delegation
Supervision
Orientation & Education
Evaluation
Staffing
67

The Patient
Self-Determination Act
Requires health care organizations that
receive federal funding to provide education for
staff and patients on issues concerning
treatment and end-of-life issues. (They have to
ask about Advanced Directives and what not on
admission and inform them about it)
68

Whistleblower Act
To prevent employers from taking
retaliatory action against nurses such
as suspension, demotion,
harassment or discharge for
reporting improper patient care or
business practices

Good Samaritan Act

Generally, a nurse is not liable for
injury that occurs as a result of
emergency treatment, provided
that:
Care is provided at the scene of
emergency
The care is not grossly negligent
70

Health Insurance
Portability and
Accountability Act
Protects the privacy of health
information
Administrative Simplification plan
All related to electronic medical records,
simplifying exchange of info and what not, by
2014 all hospitals have to have this

Privacy Rules

71

Diverse Workforce
Title VII (Civil Rights Act-1964):
Protects against discrimination based on race,
color, creed, national origin, religion or sex

Age Discrimination in Employment:

no discrimination over age 40

American with Disabilities Act: no

discrimination against physical or mental
impairment regarding hiring
72

Diverse Workforce
Equal Pay Act: no discrimination against
women

Occupational Safety & Health Act:

safe and healthy work environment

Family & Medical Leave Act:

provides job security for taking leave of
absence

Joint Commission
Independent not for profit organization
that accredits and certifies healthcare
organizations
Purpose: continuously improve health care
for the public, in collaboration with other
stakeholders, by evaluating health care
organizations and inspiring them to excel in
providing safe and effective care of the
highest quality and value
http://www.jointcommission.org/AboutUs/

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

Joint Commission
National Patient Safety Goals cont.:
Accurately and completely reconcile
medications across the continuum of care
Reduce the risk of patient harm resulting from
falls
Prevent healthcare associated pressure ulcers
The organization identifies safety risks
inherent in its patient population
Universal protocol
http://www.jointcommission.org/AboutUs/

Centers for Medicare &

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

Centers for Medicare &

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

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