Legal and Professional Issues in Ethical Caring

By Dr.(Mrs.) S.Valliammal Lecturer CON NIMHANS

Legal Aspects

Legal regulation of nurses through state registration

Assurance to public that nurses are prepared and competent Confer autonomy with legal limitations Contd..

Legal Aspects

With autonomy comes accountability for decisions and actions As autonomy and responsibility increase, so does the level of accountability and liability Nurse Managers have the major responsibility for upholding the standards of care for the staff

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

Legal Aspects
:
Two classes of wrongful acts

Criminal Acts Conduct that is harmful or offensive to society Civil Acts Wrongs that violate rights of individuals

Civil Acts

Judicial Risk Torts Negligence Malpractice Intentional Torts Strict Liability Torts Breach of Contracts Contd..

Civil Acts

Judicial Risk Uncontrollable variables that increase risk (judge / jury having a bad day; suing another without real justification) Contd..

Civil Acts

Tort wrongful act committed against another person, organization, or property that causes harm Personal (Direct) Liability imposed on the person who committed the wrongful act.

Vicarious (Indirect) Liability imposed on a person or organization that did not commit an act, but is associated with the liable person. Contd..

Civil Acts

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

Civil Acts

Breach of Contracts

Legal Concerns

Nurse Managers are responsible for: Upholding policies of their healthcare organization.

Ensuring that laws of society at local, state and national levels. (including anti-discrimination laws, employee-related laws, etc.) Ensuring that management and employees follow policies and laws. Contd

Legal Concerns
Three Main Areas of Legal Concerns

Personal negligence in clinical practice Liability for delegation and supervision Liability of health care organizations Contd.

Personal Negligence in Clinical Practice

Ethical obligation to non-maleficence (do no harm)

Professional Negligence unreasonable actions failure to meet standards failure to act and prevent harm Contd..

Four Elements of Professional Liability To establish legal liability injured party (plaintiff) must prove:

1) 2) 3) 4)

Duty of care was owed to injured party There was breach of that duty The breach of duty caused injury Plaintiff suffered actual harm or damages

Common Examples of Negligence

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

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

Liability for Delegation and Supervision

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

CLINICAL SCENARIO

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

Liability of Health Care Organizations

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

Implications for the Nurse

The best defense is a good offense.

Be knowledgeable about

Nurse Practice Act Scope of practice of other staff Standards of Care Code of Ethics and Interpretive Statements Hospital policies and procedures

Contd.

Maintain all current licensing, certification and training requirements.

Keep current in nursing knowledge thru continuing education. Strive to provide the highest quality of care for all. Set priorities carefully. Be aware of problem areas. Be proactive; take precautions to decrease injury. Contd.

Documentation Truthful / accurate / Complete Objective / non-judgmental Legible Utilize appropriate abbreviations Maintain honest, caring, respectful relationship with patients. Report unsafe, unethical practices of self and others thru proper channels. Follow proper delegation and supervision guidelines.

Reporting Patient Care Issues

Talk to the appropriate person in private Clarify problem Observe professional courtesies Provide facts and supportive evidence File complaints of unsafe acts within the facility Communicate through chain of command If problem, urgent may need to speak with manager or supervisor immediately. May need to notify risk manager Follow hospital / Institution policy May remain anonymous

Identifying Signs of Impairment

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

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

Impaired Nurse
May be a candidate for:
Self-referral or board referral Monitoring system with guidelines Cease practice, agree to assistance & seek evaluation & treatment Disciplinary action

Essential Values for the Professional Nurse

Altruism Equality Esthetics Freedom Human dignity Justice Truth

What is an ethical issue?

When you have to judge what is right or wrong Choosing between options Deciding whether to do something or do nothing Should I or shouldnt I ?

Weighing up the potential impact of your decisions or actions

A dilemma making a difficult choice

Ethical Issues in Clinical Nursing

Ethical dilemmas Deciding between right and wrong when all alternatives are equally unfavorable

Conflicts can be between: Professional ethics and organization ethics Two ethical duties to the patient Professional ethics and personal or religious ethics Duties to family / self and duties to patient

Dilemmas for Nurse Professionals

Life and death Quality of life

Right to decide
Informed consent Alternative treatment issues

Dilemmas Created by Technology

Illnesses once leading to mortality are now classified as chronic illnesses Cost is a consequence of prolonging life with technology

Four Key Ethical Principles

1)

Autonomy (self-detemination)
Beneficience (doing good) Non maleficence (doing no harm)

2)

3)

4)

Justice (fairness to all; equal treatment and distribution)

Purpose of Ethical Principles

Establish common ground between nurse, patient, family and other health care professionals and society to discuss ethical questions and make ethical decisions. Permit people to take a consistent position on specific or related issues. Provide an analytical framework by which moral problems can be evaluated.

Ethical rules

Veracity truth telling, informed consent, respect for autonomy. Privacy a persons right to remain private, to not disclose information . Confidentiality only sharing private information on a need to know basis. Fidelity loyalty, maintaining the duty to care for all no matter who they are or what they may have done.

Ethical Decision Making in Nursing Practice

1.

Situation assessment procedure: Identify ethical issues and problems

2.

Identify and analyze available alternatives

Select one alternative Justify the selection Contd

3.

4.

Identify Ethical Issues and Problems

What is the issue?

What are the hidden issues? What are the complexities of the situation?

Is anything being overlooked?

Contd

Identify and Analyze Available Alternatives

What are the reasonable possibilities for action? How do different parties want to resolve the problem? What ethical principles are required for each alternative? What assumptions are required, and what are their implications for future actions? What additional ethical problems do alternatives raise? Contd..

Select One Alternative

Integration of multiple factors Blend ethical theory, principles and values Contd

Justify the Selection

Specify reasons for action Clearly present ethical basis for these reasons Understand the shortcomings of the justification Anticipate objections to the justification Contd

Ethical Dilemmas
Common Ethical Dilemmas in nursing care practice:

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

Ethical Challenges

Veracity
Paternalism Autonomy Accountability

CLINICAL SCENARIO

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

CLINICAL SCENARIO

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

CLINICAL SCENARIOS

A patient and his family offer you money/ material for giving such good care to the patient. What would you do? You discover that you are HIV+ve .Should you tell your employer or coworkers?

CLINICAL SCENARIO

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

CLINICAL SCENARIO

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

Conclusion
As nurses, we need to maintain high standards of patient care through updates in nursing Scholarly work must be conducted responsibly and ethically to improve the standard of nursing care.

Contd

Dont take things that arent yours (Fulghum, 1989).

Any Questions

References

Beauchamp T and Childress J (2001) Principles of Biomedical Ethics 5th Edition Oxford University Press Hunt G (1994) Ethical Issues in Nursing Routledge. London Seedhouse D (1998) Ethics the heart of Health Care Wiley. Winchester. Watt H (2000) Life and Death in Health Care Ethics Routledge. London
http://www.iep.utm.edu/e/ethics.htm#SH2a http://www.nursingethics.ca/articles.html http://www.freedomtocare.org/iane.htm http://www.lib.flinders.edu.au/resources/sub/healthsci/a-zlist/ethics.html