L&E Chapter 003


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  • Constitutional laws, both federal and state, provide for basic rights and create the legislative bodies (senate and assembly) that write laws governing our lives.
  • In health care, agencies such as the Department of Health and Human Services or Office of Professional Licensing oversee nursing and the other health care professions. Who is governed by administrative laws?
  • You may be guilty of a tort if you harm a patient, for example, by administering the wrong dose or type of medication. Serious crimes are called felonies and are punished with long prison terms of a year of more, or even the death penalty; less serious crimes are misdemeanors and may result in prison terms of less than a year, monetary fines, or both. What is another example of a situation in which a nurse may be guilty of a tort?
  • State licensure is required to practice nursing in the United States, and each state writes its own laws and regulations regarding licensure. How does our state’s nurse practice act delineate responsibilities and degrees of independence of RNs, VNs, and other nurses?
  • A passing score on the NCLEX-PN ® test is accepted by the states for initial licensure when all other state requirements for eligibility are met. Ask students to share their views on the licensure examination, its format, level of difficulty, and test preparation strategies. Although a growing number of states have developed reciprocity agreements, nurses who wish to practice in more than one state may need to apply for the nursing license in each state in which they practice. How would national licensure benefit the nurse?
  • Although a student nurse may not perform a task as quickly or as smoothly as the licensed nurse, the student will achieve the same outcome without harm to the patient. The instructor who supervises a student is responsible for proper instruction and adequate supervision and evaluation of a student. Instructors are responsible for assigning students to patients of an appropriate level of complexity so that they do not jeopardize patient safety.
  • Accountability means asking for assistance when unsure, performing nursing tasks in the safe and prescribed manner, reporting and documenting assessments and interventions, and evaluating the care given and the patient's response to that care. In addition to health care, what are some of the other types of professionals that are facing increased accountability lately? Discuss sources of continuing professional education, and ask students to provide examples in which friends and coworkers are pursuing continuing education.
  • Some states make a distinction between delegation (only to another licensed person) and assignment (to an unlicensed person). The nurse is responsible for ensuring patient safety and the observation of patient rights. Discuss a hierarchy of clinical and administrative tasks that might be delegated to each level of nursing trainee or professional. What steps might a licensed nurse take to ensure the person can handle the assignment safely?
  • Legally, a nurse is responsible for her or his actions under the nurse practice act and according to the standards of care that are approved by the profession. Standards are defined in nursing procedure books, institutional manuals of policies and procedures or protocols, and nursing journals that outline current skills or techniques. In what ways does the availability of written standards help the nursing student and the licensed nurse (in general and specifically for the procedure in question)?
  • When a licensed nurse is charged with a violation of a nurse practice act, there will be a hearing to determine if the charges are true. What may result when a nurse is found guilty of professional misconduct?
  • Nurses may stay current by attending programs provided by their employer; through participation in their professional organization; by attending workshops, seminars, or presentations on health care topics; by reading professional nursing journals; by formal continuing education in colleges; or by correspondence courses.
  • Discuss the federal government’s or your state’s role in ensuring compliance with OSHA. What experience with OSHA standards or documentation have students had? What would students do if OSHA requirements were not being followed in a practice setting in which they worked?
  • What may give health care personnel a clue that child abuse may have occurred? Discuss legal requirements in cases of suspected child abuse or neglect. What is the correct reporting chain of command for such incidents?
  • In 1964, federal legislation made it illegal for employers to discriminate (to hire, promote, or fire employees on the basis of race, color, religion, sex, or national origin). The law has been amended to include protection for people with disabilities, as well as discrimination based on age. To whom should students report discrimination they experience in the workplace?
  • In our society, in which sexual comments and activities are commonplace on television or in movies, we must be aware of the right time and place for sexually suggestive or explicit words or touch. What should you, as a nurse, do if you are being sexually harassed?
  • In most states, there is no legal requirement for a nurse to provide aid in an emergency. Who do the Good Samaritan laws NOT apply to? Why are these laws important to public health and safety?
  • Under some legally specified conditions, certain rights may be temporarily suspended, such as in an emergency when the patient is unconscious or unable to communicate. Who developed the “Patient’s Bill of Rights”? Ask students their views on why patients’ rights have come to the forefront of health care. What does the trend tell us about the profession and those served by the health care industry?
  • The Joint Commission's National Patient Safety Goals are updated every year, and are available on their website (www.jcipatientsafety.org). The National Patient Safety Goals and requirements apply to nearly 15,000 hospitals and health care organizations that are accredited by The Joint Commission. What are the differences in the way nurses and physicians are taught to communicate patient information?
  • The patient does have the right of access to the chart, and copies of information in the chart may be authorized by the patient to be provided to other agencies. The medical record contents always need to be accurate, pertinent, and timely. On what should charting be focused? How are electronic medical records, written records, and oral conversations safeguarded?
  • It is important that the nurse makes certain that she has the patient’s consent to relay information about his health care to family members. How can a patient have information sent to another agency, physician, or insurance company?
  • If the patient has any questions, they should be satisfactorily answered before the patient signs the consent. It is important to determine that proper consent has been obtained, both legally and ethically. Failure to obtain a valid informed consent may lead to charges of assault and battery, or invasion of privacy.
  • Do you need to know the content of a legal document when you are witnessing a signature on that document?
  • All 50 states recognize advance directives, but each state regulates advance directives differently, and an advance directive from one state may not be recognized in another, depending on the similarities or differences in their laws. Who writes a DNR order and what does it mean?
  • In nursing malpractice, a reasonably prudent person is a similarly educated, licensed, and experienced nurse. In order to prove malpractice, four elements must be present: duty, a breach of duty, causation, and injury. Ask students to provide an example of each illegal act.
  • What is litigation?
  • Adults who are alert and oriented have the right to refuse medications, baths, treatments, dressing changes, irrigations, insertion of a catheter, and diagnostic tests as well as surgery. It is the nurse’s responsibility to explain the reason why a particular drug or treatment is important. If the patient still refuses, the nurse should obtain a release from liability because the treatment is not done or the drug is not taken.
  • A person sued for slander or libel may be found innocent if the statements made were true, or were said or written with no intent to harm the person, but for a justified purpose. Ask students to provide an example of each illegal act.
  • When patients entrust themselves to our care, it is with the expectation of confidentiality—that what is told to the health care professional and what is learned about the patient’s health and personal history is private information to which no one else should have access. What is a growing area of concern regarding privacy?
  • When a person wants to leave the hospital against the advice of the physician, a release to leave "against medical advice" (AMA) is used. What information may policies require be given to the patient signing an AMA?
  • Nurses must be alert to the abuse of protective devices when other less restrictive techniques may be effective. Nurses should consult with their supervisor about using protective devices in an emergency situation when no physician order is available.
  • Establishing rapport and effective communication skills can create a relationship in which patient anger or misunderstanding can be resolved rather than grow to lawsuit proportions. What should the nurse do if hospital rules are out-of-date or unrealistic?
  • Incident reports should be timely, factual, and concise, and should not contain unnecessary details, such as explanations about why the event might have occurred. How does the incident report benefit the facility?
  • Most authors agree that it is unwise to rely on your employer's liability insurance policy to protect you because there may be situations in which the interests of the institution are at odds with your legal interests.
  • There are no prescribed legal penalties for violating a code of ethics, although in many instances, violation of a professional code of ethics may result in disciplinary action by a licensing or regulating agency. What are ethics closely linked to?
  • The International Council of Nurses (ICN), the American Nurses Association (ANA), the National Association for Practical Nurse Education and Service (NAPNES), and the National Federation of Licensed Practical Nurses (NFLPN) have developed codes of ethics for nurses. Who has set standards for nursing since 1941?
  • On a daily basis, nurses face personal ethical decisions involving honesty, whistle-blowing (reporting illegal or unethical actions), and provision of care. Our professional code of ethics dictates that we act as patient advocates and safeguard our patients from harm. What values does the nurses’ code of ethics promote?
  • L&E Chapter 003

    1. 1. Chapter 3 Legal and Ethical Aspects of Nursing
    2. 2. <ul><li>Chapter 3 </li></ul><ul><li>Lesson 3.1 </li></ul>
    3. 3. Learning Objectives <ul><li>Theory </li></ul><ul><li>Explain legal requirements to practice nursing and how they relate to a student nurse. </li></ul><ul><li>Identify consequences of violating a nurse practice act </li></ul><ul><li>Examine professional accountability, professional discipline, and continuing education for licensed nurses </li></ul><ul><li>Describe NAPNES standards of practice </li></ul>
    4. 4. Learning Objectives <ul><li>Clinical Practice </li></ul><ul><li>Note how laws on discrimination, workplace safety, child abuse, and sexual harassment affect your practice </li></ul><ul><li>Discuss the National Patient Safety Goals and where these can be found </li></ul><ul><li>Interpret patient rights in a hospital, nursing home, community setting, or psychiatric facility </li></ul>
    5. 5. Source of Law <ul><li>Laws are rules of conduct that are established by our government </li></ul><ul><li>Three sources </li></ul><ul><ul><li>The Constitution and Bill of Rights </li></ul></ul><ul><ul><li>Laws made by elected officials </li></ul></ul><ul><ul><li>Regulations made by agencies created by elected officials </li></ul></ul>
    6. 6. Source of Law <ul><li>Constitutional law provide for basic rights and create legislative bodies </li></ul><ul><li>Judicial law results when a law or court decision is challenged and the judge affirms or reverses the decision </li></ul><ul><li>Administrative law comes from agencies created by the legislature </li></ul>
    7. 7. Civil and Criminal Law <ul><li>Civil law </li></ul><ul><ul><li>Guarantees individual rights </li></ul></ul><ul><ul><li>A tort is a violation of civil law </li></ul></ul><ul><li>Crime </li></ul><ul><ul><li>A wrong against society </li></ul></ul><ul><ul><li>Imprisonment and/or fines may result if one is convicted of a crime </li></ul></ul>
    8. 8. Nurse Practice Acts <ul><li>Define the scope of nursing practice </li></ul><ul><li>Regulate the profession by a state’s board of nursing </li></ul><ul><li>Include the definition of nursing for the RN and the LPN or LVN and may include definitions for advanced practice nurses </li></ul>
    9. 9. Licensure <ul><li>Eligibility determined by state’s board of nursing </li></ul><ul><li>Each state sends a representative to the National Council of the State Boards of Nursing, which develops the National Council Licensure Examination (NCLEX)® </li></ul><ul><li>Passing score on NCLEX-PN® is accepted in all states as one requirement for licensure </li></ul><ul><li>Reciprocity or recognition of one state’s nursing license by another state is a current issue </li></ul>
    10. 10. Student Nurses <ul><li>Held to the same standards as a licensed nurse </li></ul><ul><li>Legally responsible for their own actions or inaction </li></ul><ul><li>Have responsibility to consult with instructor when unsure in a situation, or when patient's condition is changing rapidly </li></ul><ul><li>Need to know their state’s nurse practice act </li></ul>
    11. 11. Professional Accountability <ul><li>Nurse’s responsibility to meet health care needs of patient in a safe and caring way </li></ul><ul><li>Students must apply classroom learning and theory in the clinical setting </li></ul><ul><li>Accountability entails a commitment to stay current and knowledgeable </li></ul>
    12. 12. Delegation <ul><li>The assignment of duties to another person </li></ul><ul><li>LPN may supervise nursing assistants, technicians, or other LPNs </li></ul><ul><li>Delegating nurse’s duty is to supervise and evaluate care that a licensed or unlicensed person provides </li></ul>
    13. 13. Standards of Care <ul><li>Provide a way of judging the quality and effectiveness of patient care </li></ul><ul><li>In legal cases, determine whether a nurse acted correctly </li></ul>
    14. 14. Professional Discipline <ul><li>State boards of nursing are responsible for discipline within the profession </li></ul><ul><li>Most common charges brought against nurses include substance abuse, incompetence, and negligence </li></ul><ul><li>It is considered negligence not to report another professional’s misconduct </li></ul>
    15. 15. Continuing Education <ul><li>Many states have laws that require evidence of continuing education after a nurse has passed the licensing exam </li></ul><ul><li>Nurses must continue their education to keep abreast of changes in health care practice, pharmacology, and technology in order to practice safely </li></ul>
    16. 16. Laws and Guidelines Affecting Nursing Practice <ul><li>Occupational Safety and Health Act </li></ul><ul><li>Child Abuse Prevention and Treatment Act </li></ul><ul><li>Discrimination </li></ul><ul><li>Sexual harassment </li></ul><ul><li>Good Samaritan laws </li></ul><ul><li>Patients’ Rights </li></ul><ul><li>National Patient Safety Goals </li></ul><ul><li>Health Insurance Portability and Accountability Act (HIPAA) </li></ul><ul><li>Consents and releases </li></ul>
    17. 17. Occupational Safety and Health Administration (OSHA) <ul><li>Regulations on handling infectious/toxic materials, radiation safeguards, and electrical equipment </li></ul><ul><li>Requires orientation and education in topics such as blood-borne pathogens, exposure, fire, bomb threats, lifting and evacuation procedures </li></ul><ul><li>Requires facilities to keep a record of hazardous substances as well as material safety data sheets (MSDS) </li></ul>
    18. 18. Child Abuse Prevention and Treatment Act (CAPTA) <ul><li>Defines child abuse and neglect </li></ul><ul><ul><li>“ Any recent act, or failure to act, that results in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse, or exploitation of a child by a parent or caretaker who is responsible for the child’s welfare” </li></ul></ul><ul><li>Licensed health care personnel required to report child abuse </li></ul>
    19. 19. Discrimination <ul><li>Making a decision or treating a person based on a class or group to which he belongs, such as race, religion, or sex, rather than on his individual qualities </li></ul><ul><li>Illegal for employers to ask questions on an employment application that would indicate race or other protected categories, or health status </li></ul>
    20. 20. Sexual Harassment <ul><li>Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature </li></ul><ul><li>Illegal when used as a condition of employment or promotion or when it interferes with job performance </li></ul>
    21. 21. Good Samaritan Laws <ul><li>Protect a health care professional from liability if he stops to provide aid in an emergency </li></ul><ul><li>Liability is limited unless there is evidence of gross negligence or intentional misconduct </li></ul>
    22. 22. Patient’s Rights <ul><li>Revised to “The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities” in 2003 </li></ul><ul><li>An ethical, not a legal, document </li></ul><ul><li>Seeks to preserve patient’s dignity, privacy, freedom of movement, and information needs </li></ul><ul><li>State legislators have written laws that prohibit certain actions or guarantee particular rights </li></ul>
    23. 23. National Patient Safety Goals <ul><li>Provide evidence- and expert-based solutions to problem areas in terms of patient safety </li></ul><ul><li>Sentinel event </li></ul><ul><ul><li>An unexpected patient care event that results in death or serious injury (or risk thereof) to the patient </li></ul></ul><ul><ul><li>Most frequent cause is lack of communication among caregivers </li></ul></ul>
    24. 24. <ul><li>Chapter 3 </li></ul><ul><li>Lesson 3.2 </li></ul>
    25. 25. Learning Objectives <ul><li>Theory </li></ul><ul><li>Explain legal requirements to practice nursing and how they relate to a student nurse </li></ul><ul><li>Compare and contrast terms “negligence” and “malpractice” </li></ul><ul><li>Discuss how to protect yourself from lawsuits or damages </li></ul><ul><li>Differentiate a code of ethics from laws or regulations governing nursing, and compare the similarities of the codes of ethics from the NFLPN, NAPNES, and ANA </li></ul>
    26. 26. Learning Objectives <ul><li>Clinical Practice </li></ul><ul><li>Describe three factors necessary for informed consent </li></ul><ul><li>Explain advance directives and the advantage of having them written out </li></ul>
    27. 27. The Chart or Medical Record <ul><li>A legal document that includes records of all assessments, tests, and care provided </li></ul><ul><li>Kept confidential </li></ul><ul><ul><li>Only people directly associated with the care of that patient have legal access to information in the chart </li></ul></ul><ul><li>Property of the hospital or agency or physician, not the patient </li></ul>
    28. 28. Health Insurance Portability and Accountability Act (HIPAA) <ul><li>Regulations regarding patient privacy and electronic medical records </li></ul><ul><li>Failure to comply with the rules may lead to civil penalties </li></ul><ul><li>Intentional violation of the regulations can lead to sizable fines and time in jail </li></ul>
    29. 29. Consent <ul><li>Legal document that records the patient’s permission to perform a treatment or surgery, or to give information to insurance companies or other health care providers </li></ul><ul><li>Informed consent </li></ul><ul><ul><li>Indicates patient’s participation in decision making </li></ul></ul><ul><ul><li>Person signing must know what the consent allows and be able to make a knowledgeable decision </li></ul></ul>
    30. 30. Release <ul><li>Legal form to excuse one party from liability </li></ul><ul><li>Common release is a Leave Against Medical Advice (Leave AMA) </li></ul><ul><li>May also refer to forms used to authorize an agency to send confidential health care information to another agency, school, or insurance company </li></ul>
    31. 31. Witnessing Wills or Other Legal Documents <ul><li>Most hospitals and health care agencies have policies against witnessing wills or legal documents </li></ul><ul><li>If will is contested, nurse could be called to testify regarding the patient’s health or mental condition, or relationship to visitors </li></ul>
    32. 32. Advance Directives <ul><li>Allow a person to plan for/communicate medical wishes if unable to do so himself </li></ul><ul><li>Durable power of attorney </li></ul><ul><ul><li>Gives legal power to a health care agent </li></ul></ul><ul><ul><li>Person is chosen by the patient to follow the patient’s advance directives and make medical decisions on his behalf </li></ul></ul>
    33. 33. Negligence and Malpractice <ul><li>Negligence </li></ul><ul><ul><li>Failing to do something a reasonably prudent person would do, or doing something a reasonably prudent person would NOT do </li></ul></ul><ul><li>Malpractice </li></ul><ul><ul><li>Negligence by a professional person </li></ul></ul><ul><ul><li>Not acting according to professional standards of care as a reasonably prudent professional would </li></ul></ul>
    34. 34. Common Legal Issues <ul><li>Nurses have access to private information and personal contact </li></ul><ul><li>When legal boundaries are violated, and injury occurs, nurses may be subject to litigation </li></ul>
    35. 35. Assault and Battery <ul><li>Assault </li></ul><ul><ul><li>The threat to harm another, or even to threaten to touch another without that person’s permission </li></ul></ul><ul><li>Battery </li></ul><ul><ul><li>Actual physical contact that has been refused or that is carried out against the person’s will </li></ul></ul>
    36. 36. Defamation <ul><li>One person makes remarks about another person that are untrue, and the remarks damage that other person’s reputation </li></ul><ul><li>Two types </li></ul><ul><ul><li>Slander (oral) </li></ul></ul><ul><ul><li>Libel (written) </li></ul></ul>
    37. 37. Invasion of Privacy <ul><li>A violation of the confidential and privileged nature of a professional relationship </li></ul><ul><li>Unauthorized persons learn of the patient’s history, condition, or treatment from the professional caregiver </li></ul><ul><li>Leaves patients in a position that might cause loss of dignity or embarrassment </li></ul>
    38. 38. False Imprisonment <ul><li>Preventing a person from leaving, or restricting movements in the facility </li></ul><ul><li>When involuntary admission is made against patient’s wishes, to protect him from self-harm or from harming others, he may be detained without consent for a short time </li></ul>
    39. 39. Protective Devices <ul><li>The inappropriate use of devices that limit a person’s mobility can result in charges of false imprisonment </li></ul><ul><li>Devices may be mechanical or chemical </li></ul><ul><li>Physician order needed for any protective device </li></ul>
    40. 40. Decreasing Legal Risk <ul><li>Nursing competence </li></ul><ul><li>Incident or occurrence reports </li></ul><ul><li>Liability insurance </li></ul>
    41. 41. Nursing Competence <ul><li>Possessing skill, knowledge, and experience necessary to provide adequate nursing care </li></ul><ul><li>Documentation: key in proving nursing actions used were appropriate, protecting nurse from liability </li></ul><ul><li>Lawsuits may be avoided by early identification of dissatisfied patients </li></ul>
    42. 42. Incident or Occurrence Reports <ul><li>Document occurrence that is out of the ordinary </li></ul><ul><li>Document what happened, the facts about the incident, and who was involved or witnessed it </li></ul><ul><li>Generally not filed as part of the patient’s chart; no reference to the incident report is made in the patient's chart </li></ul>
    43. 43. Liability Insurance <ul><li>Protects the livelihood and assets of a nurse should the nurse get sued </li></ul><ul><li>Pays for lawyer to defend the nurse and any award won by plaintiff up to limits of the policy </li></ul><ul><li>May also pay for attorney costs and related costs if the nurse is subjected to review by the state board of nursing </li></ul>
    44. 44. Ethics in Nursing <ul><li>Ethics are rules of conduct that have been agreed to by a particular group </li></ul><ul><li>These rules are agreed to be morally right or proper for that group </li></ul><ul><li>Ethics are different from laws, in that they are voluntary </li></ul>
    45. 45. Codes of Ethics <ul><li>A respect for human dignity, the individual, and provision of nursing care that is not affected by race, religion, lifestyle, or culture </li></ul><ul><li>A commitment to continuing education, maintaining competence, and contributing to improved practice </li></ul><ul><li>The confidential nature of the nurse-patient relationship, outlining behaviors that bring credit to the profession and protect the public </li></ul>
    46. 46. Ethical Dilemmas <ul><li>Life-prolonging treatment versus refusing such treatment </li></ul><ul><li>Initiating or terminating life support or treatment </li></ul><ul><li>Assisted suicide </li></ul><ul><li>Euthanasia </li></ul>