Dr. Dayanand B

ETHICAL AND LEGAL ISSUES
IN EVIDENCE BASED
NURSING PRACTICE
Dr. DAYANAND BELAGAVI
ASSISTANT PROFESSOR
SUMANDEEP NURSING COLLEGE
SUMANDEEP VIDYAPEETH,
An Institution Deemed to be University,
Accredited by NAAC with a CGPA of 3.53 , ‘A’ Grade
PIPARIA, WAGHODIA, VADODARA
GUJARAT - 391760

OBJECTIVES
Understand the concept of ethical and legal
Describe the ethics, code of ethics, key principles, need
for ethics
Discuss the ethical theories, ethical dilemmas, decision
making, professional conduct, role of nurse in ethical
issues.
Discuss the law in nursing, tort and malpractice in
nursing.
Describe the issues in patient care, employment,
management , medico legal issue.
 Understand the ethics in research and evidence based
practice
Dr. Dayanand B, Asst. Prof., Sumandeep Nursing College, Sumandeep Vidyapeeth, Vadodara

 Role of nurse continues to expand & is influenced by many
aspects.

Best Practices
protect license, quality of care & reduce risk
School/college: Learn to obtain license
After school/college: Learn to maintain/protect/keep license

What is Ethics?
“Ethics are the rules or principles that govern
right conduct and are designed to protect the
rights of human beings”
- Sister Nancy

CODE OF ETHICS
A code of ethics is a set of ethical principles
that are accepted by all members of a
profession.”
- Potter and Perry

Need for Nursing Ethics
Practice ethically
Identify the ethical
issues in work place
Respond to ethical
conflicts
Differentiate right
/wrong behavior
Professional behavior
Prevent below standard
practice
Protect a nurse if falsely
accused
Help teachers to plan
education

Key Principles of Ethics in health Care System

1. Autonomy :The right of self determination, independence
and freedom. Right to health care decision.
2. Justice-Obligation to be fair with all people.
3. Fidelity- Obligation of an individual to be faithful to the
commitment made to himself, and to others.
4. Veracity: - The duty to tell the truth.
5. Beneficence- Doing good for the client. What exactly is
good for one person may not be the same for others.
6. Non-maleficence- is the requirement that health care
providers do no harm to their client either intentionally or
unintentionally.
7. Deontological:-What causes a good outcome is good
action.

Code of Ethics In Nursing Practice
Within any given profession, a code of ethics
serves as a means of self-regulation and a
source of guidelines for individual behaviour
and responsibility.

I.C.N CODE OF ETHICS FOR NURSES(1993)
Elements of the code:-
Nurses and people
Nurses and practice
Nurses and Society
Nurses and Co-workers

• Nurse practices with compassion and respect for the
inherent dignity, worth and uniqueness of every
individual.
• The nurses primary commitment is to patient.
• The nurses promote, advocates for the strives to
protect the health, safety and rights of the patient.
• The nurse is responsible and accountable for individual
nursing practice and determines the appropriate
delegation of tasks.
• The nurse owns the same duties to self as others
including the responsibility to preserve integrity &
safety.
• Advancement of profession
AMERICAN NURSES ASSOCIATION CODE OF
ETHICS

• The nurses participates in establishing,
maintaining and improving health care
environments
• Advancement of the profession.
• The nurses collaborates with others
health professional and the public.
• Responsible for articulating nursing
values for maintaining the integral of
the profession and its practice for
shaping the social policy.
Contd.

CANADIAN NURSES ASSOCIATION CODE OF ETHICS
FOR NURSING
• Health and Well being
• Choice
• Dignity
• Confidentiality
• Fairness
• Accountability
• Practice Environment

TYPES OF ETHICAL THEORIES
1. Duty-oriented ethical theories: A duty
oriented ethical theory is a system of ethical
thinking having the concept of duty or
obligation as foundation.
2. Rights-Oriented Ethical theories: A rights-
oriented ethical theory is a system of ethical
thinking having the concept of rights as a
foundation.

Duty Oriented Ethical Theories
Duties
Right
Goal
Rights Oriented Ethical Theories
Right
Duties
Goal

3. Goal-oriented ethical theories: system of
ethical thinking having the concept of
maximizing the overall goal as its foundation
Goal-Oriented Ethical Theories
Duties Rights

4. Intuitionist ethical theory
An ethical theory is a system of ethical thinking
that balances goals, rights and duties according
to the situation.
Intuitionist Ethical Theories
Duties Goals Rights

ETHICAL DILEMMAS
 A dilemma is defined as a situation requiring a
choice between two equally desirable or
undesirable alternatives.
 Staff nurses and nurse managers face difficult
decisions caused by tensions between
technological capabilities, budgetary strictures,
and quality of life concerns.
Eg:
• With holding/with drawing nutrition and fluids
• Starting / discontinuing life support system

Decision Making
is a system at the step-by –step approach to
resolving problems that deals with a client‘s
health and well-being.
Step – I: Collect, Analyze and interpret the data
Step – II: State the Dilemma
Step – III: Consider the choices of action
Step – IV: Analyze the advantage and
disadvantages of each course of action
Step– V: Make the decision and act on it.

PROFESSIONAL CONDUCT
Professional responsibility and
accountability
Nursing Practice
Communication and interpersonal
relationships
Valuing human being
Management

ROLES AND FUNCTIONS OF ADMINISTRATOR IN
ETHICAL ISSUES

• Self aware regarding own values and basic beliefs about the
rights, duties and goals of human beings.
• Accepts that some ambiguity and uncertainty be a part of all ethical
decision-making.
• Accepts that negative outcomes occur in ethical decision making
despite high quality problem solving and decision-making.
• Demonstrates risk taking in ethical decision making.
• Role models ethical decision-making which are congruent with the
code of ethics and inter respective statements.
• Actively advocates for clients, subordinates and the profession.
• Clearly communicates expected ethical standards of behavior.
• Uses a systematic approach to problem-solving or decision making
when faced with management problems with ethical
ramifications.
• Identify outcomes in ethical decision-making that should always
be sought to avoided.

Self aware regarding
values and beliefs Accepts uncertainty in
ethical decision making
Negative outcome
Demonstrates risk taking
in ethical decision
making

Advocates for client,
subordinate &
profession
Communicates expected
ethical standards of
behavior
Uses a systematic
approach
Identify outcomes in ethical
decision-making that
should be avoided

LAW
• Something which lies fixed or events.
• Definition :The law is a system of rights and
obligations which the state enforces.
By Green

Purposes of law: Safeguarding the
Nurse
Licensure
Good
Samaritan
laws
Good
rapport
Standards of
care
Standing
orders
Consent for
operation
and other
procedures
Correct
identity Counting of
sponge,
instrument
and
needles
Contracts
Documentation

LAW IN NURSING
• Common law : Created by judicial decisions made in
courts when individual cases are decided.
• Felony : Is a crime of serious nature that has a penalty of
imprisonment for greater than one year or even death.
• Misdemeanor: Is a less serious crime that has a penalty of
a fine or imprisonment of less than one year.
• Civil law: Protects the rights of individual persons within
our society and encourage fair and equitable treatment
among people.
• Contract Law : It is the enforcement of agreements among
private individuals.
• Criminal law: Prevent harm to society and provides
punishment for crimes.

• Torts are civil wrongs committed by one person against
another
• A tort law allows an injured person to seek damages a
person who caused the injury.
Types of Tort
I. Intentional tort
II. Un-intentional tort

Aruna Shanbaug: An Indian nurse who spent 42 years in a
persistent vegetative state after being raped and strangled.

I. Intentional tort
A. Assault: Assault is any intentional threat to
bring about harmful or offensive contact.
B. Battery: Battery is un-consented or
unlawful touching of a person
C. Defamation of character
 Libel: Written defamation (petition)
 Slander (oral): false spoken words
C. Invasion of privacy
D. Public disclosure
E. False imprisonment

Assault Battery
Defamation of character

False imprisonment:
Invasion of privacy

II. Un-intentional tort
A. Negligence : knowing the right thing and Not doing it.
Eg:
failing to recount the forceps during surgery
Administer drug inappropriately

B. Malpractice: knowing the right to do and doing it incorrectly
Eg:
• Medication error
• Documentation error
• Failure to follow a physician‘s orders
• Delaying patient care
• Failure to get informed patient consent

Incidents & Evidences of Malpractices
• 25 November 2018: Two nurses of Patna Medical College were
physically assaulted by the attendants of a patient.
Evidences of Malpractice
• A cross sectional study conducted in a tertiary care private sector
hospital in Lucknow among 141 staff nurses showed that
Approximately three fourth of the nurses have ever been
exposed to the violence and verbal abuse. The intense workload,
high patient expectation and substance abuse were the three
important contributing factors.
• A study done in Cairo, Nurses to know the workplace violence,
observed that nurse’s negligence and malpractice were noted to
be around 40% and 36% respectively.
• According to WHO, Between 8% and 38% of health workers
suffer physical violence at some point in their careers.

Why Nursing Malpractice is
Increasing ?
While nursing shortages are not a direct cause of nursing
malpractice, it does cause a couple of serious issues:
1. Nurses who work excessively long shifts may suffer from
fatigue, making them more prone to commit an error.
2. Hospitals and other healthcare facilities may hire
inadequately trained nurses or unlicensed nurse. The less
training a nurse has, the greater the risk of a medical error.
3. In addition, miscommunication and carelessness are not
uncommon in the healthcare setting and may directly cause
a potentially life-threatening complication or mistake.

TYPES OF NURSING
MALPRACTICE
1
2
3
4
5
6MEDICATIO
N ERRORS
FAILURE
TO
FOLLOW
PHYSICIAN
ORDER DELAYING
PATIENT
CARE
INCORRECTL
Y
PERFORMING
PROCEDURE
DOCUMENTATIO
N ERROR
FAILURE IN
INFORMED
CONSENT

Tips for avoiding malpractice claims

Document, document,
document
Date, time
Aware of the facility's policies and practices.

Good Dr. Dayanand B, Asst. Prof., Sumandeep Nursing College, Sumandeep Vidyapeeth, Vadodara

DO’S AND DON’TS FOR SAFE
PRACTICE:
1. Do document & all unusual incidences
2. Do follow policies and procedures as established
by your employing agency.
3. Do keep current year to practice.
4. Do perform procedures that you have been
thought and that are within the standard scope of
your practice.
5. Do not work as a nurse in state in which you are
not licensed .
6. Do protect the patient from injury.
7. Do not advice that is contrary to the doctor‘s
order or nursing care plan

ETHICAL COMMITTEE
Hospital
Ethics
Committee
Institutional
Ethics
Committee

LEGAL ROLE OF THE NURSE
1) Provider of Service
• Ensure that client receives competent, safe, & holistic
care
• Render care
• Supervise/evaluate that which has been delegated
• Documentation of care
• Maintain clinical competency
2) Responsibility of appointing and assigning
3) Responsibility in quality control
4) Responsibility for equipment
5) Responsibility for observation and reporting
6) Responsibility for record keeping and reporting
7) Responsibility for death and dying

PATIENT CARE ISSUES
1. Nursing Shortage
2. Health-Care Reform
3. Low salaries
4. Standard Care

MANAGEMENT ISSUES
1. Turnover
2. Lack of funding
3. Issues regarding malpractice in nursing
management
4. Ethics
5. Effects of reform, shortages, ethics and salaries
6. Issues in Nursing Curriculum Development
7. Collaboration issues

EMPLOYMENT ISSUES
1. Issues related to Nursing Shortage
2. Issues in Nurse Migration
3. The Right to Work and the Right to Practice
4. Exploitation and Discrimination
5. Essential Terms and Conditions in an Employment contract
6. Unsatisfactory work performance and termination of
employment
7. Misconduct and imposition of punishment
8. Sexual harassment at the workplace
9. Renewal of nursing registration
10. Diploma vs degree in nursing for registration to practice
nursing
11. Specialization in clinical area
12. Nursing care standards

MEDICO LEGAL ISSUES
I. Legal Issues Specific to Nursing
II. Legal Issues in specialty and practice area
• Maternal and infant & Pediatric Nursing: Problems of medication, Failure in
adequate client monitoring, Failure to adequately assess the client, Failure to
report changes in the patient, Abortions, Nursing care of new born, Informed
Consent, Prenatal Screening, In vitro fertilization (IVF), Surrogacy, Female foeticide
and infanticide, Selling the newborn for financial profit
 Medical Surgical Nursing: Burns, Falls, Injury due to the use of defective apparatus
or supplies, Injury due to administration of wrong medicine, wrong dosage and
wrong concentration, Assault and battery, Failure to report accidents, Maintenance
of records and reports, Over looked sponges, instruments needles
 Psychiatric Nursing: Informal Admission, Restraints, Discharge
 Community Health Nursing: Intentional Torts, Unintentional Torts etc.

Ethical consideration
in Nursing research

Codes of Ethics
 Nuremburg Code 1947
• Addresses voluntary participation,
• protects of subjects from harm,
• right to withdraw,
• affirmation of researcher’s credentials.

 Declaration of Helsinki 1964
• Affirms principles of Nuremburg Code
• Categorizes research into two major
categories – direct value to subjects, no
therapeutic value
• Recommendation of written consent
• Legal guardians allowed to grant permission
for subject participation – vulnerable
populations.

AMERICAN NURSES ASSOCIATION (ANA)
Guidelines
• Affirms the rights of individuals to privacy and
dignity and to freedom from injury.
• Informed consent
• Institutional review board

Grove Model for Implementing
EB guidelines in Practice

Ethical Considerations
Related to
Evidence-Based Practice

Ethical Considerations in Evidence-
Based Practice
Selecting and Using Intervention for
a Given Patient
Participating in or Advocating for
Research
Base decision on best evidence for given
patient, condition, and setting
Monitor ethical practices in research in
which one participates
Involve patients in the choice of
intervention
Assure complete and appropriate informed
consent
Appreciate the importance of research
evidence over tradition or expert
opinion
Advocate for research balancing survival
with quality of life
Recognize the psychological and
resource costs in effective intervention
Involve consumers in strategic decisions
about research directions
Avoid the use of unethical studies

Levels of EBP

Evidence-Based Practice and Ethical Issues in
Occupational Therapy & Rehabilitation
• The Status of Evidence
• Consumer Autonomy
• Evaluating Evidence
• Conflict of Interest
• Informed Consent
• Biases in Research Selection

Ethics and Evidence-Based
Practice
• Evidence-based practice is roughly the use of current
best evidence in making decisions about the care of
patients (Sackett et al. 1996)
• Four ethical concerns are found in the literature on
EBP.
1. Some types of knowledge are not included in EBP.
2. EBP runs counter to patient-centred care:
3. Testable by RCT" is not the same as "most
effective“
4. Decisions based on EBP can be unjust

Implementation of EBP based on a hierarchy of
evidence which puts RCTs at the top has resulted
in a number of ethical concerns. EBP, it is said,
can result in unethical practice where:
 it overrides the decisions of practitioners borne of
their knowledge gained through experience;
 it disempowers the ability of patients to choose
on the basis of their own ideas and values;
 it results in preference given for treatments that
are most easily tested by RCTs;
 it is used in rationing and allocation decisions
which tend to favour the existence of evidence
over the presence of need.

Good Clinical Practice (GCP)
is an international ethical and scientific
quality standard for designing, conducting,
recording and reporting trials that involve the
participation of human subjects.

THE PRINCIPLES OF ICH GCP
1. Clinical trials should be conducted in accordance with the
ethical principles that have their origin in the Declaration
of Helsinki.
2. Before a trial is initiated, foreseeable risks and
inconveniences should be weighed against the anticipated
benefit for the individual trial subject and society.
3. The rights, safety, and well-being of the trial subjects are
the most important considerations.
4. The available nonclinical and clinical information on an
investigational product should be adequate to support the
proposed clinical trial.
5. Clinical trials should be scientifically sound, and
described in a clear, detailed protocol.

6. A trial should be conducted with prior institutional review board
(IRB)/independent ethics committee (IEC) approval/favourable
opinion.
7. The medical care given to, and medical decisions made on behalf
of subjects should always be the responsibility of a qualified
physician.
8. Each individual involved in conducting a trial should be qualified
by education, training, and experience to perform his or her
respective task(s).
9. Freely given informed consent should be obtained from every
subject prior to clinical trial participation.
10. All clinical trial information should be recorded, handled, and
stored in a way that allows its accurate reporting, interpretation
and verification.

Ethical Challenges in Promoting the Implementation of
Preventive Interventions: Report of the Society of Preventive
Research (SPR) Task Force
• In 2015, the Society for Prevention Research (SPR) Board of
Directors organized a series of roundtables and establish a task force to
identify salient ethical issues encountered by prevention scientists and
community-based practitioners as they collaborate to implement
evidence-based prevention practices.
• They presented some common examples that illustrate typical
ethical dilemmas.
• They summarizes value statements that stemmed from our
discussion.
• They also conclude that the field of prevention science in general would
benefit from standards and guidelines to promote ethical behavior and
social justice in the process of implementing evidence-based prevention
practices in community settings.

Examples of prevention science
activities involved in the
implementation of evidence-based
interventions & related ethical
challenges

Activity of prevention scientist or
professional
Balancing potential benefits with ethical
challenges
Relevant core ethical
Principles
Consulting with communities, institutions &
public agencies regarding selection of
evidence-based preventive interventions for
Implementation
Potential for improving public welfare of individuals &
communities, with the interest of the consultant
Beneficence,
nonmaleficence,
autonomy, and conflict of
interest (transparency)
Forming contractual or collaborative
relationships
with communities or public agencies to
implement or scale-up EBPs
Potential for improving public welfare through
improving
the quality and effectiveness of services, with local
control
of change processes & equity in distribution of
resources
Autonomy, social justice,
integrity, conflict of interest
Implementation of EBPs that involve youth,
disadvantaged groups, minorities,
immigrants, and aboriginal peoples
Balancing interest of implementation access and
fidelity, with need for accurate information to
empower and promote best
interests and respect for self-determination of
vulnerable
Participants
Respect for persons and
cultural difference, concern
for welfare, social justice

Statements which Suggests that the
prevention scientists should
1. Be guided.
2. Respect the rights.
3. Maintain high standards of transparency
4. Provide accurate and complete information about the generalizability
of available evidence, available choices, and costs of EBPs.
5. Disclose financial and professional conflict of interests or limitations
of expertise
6. Respect diverse values, beliefs, and cultures of the community or
population
7. Respect the autonomy of communities and their members.
8. Make data and complete results (significant and not significant).
9. Maintain positive relationships with their partner communities,
institutions, and public agencies.

Evidence -1
Knowledge regarding law and ethics among
nurses at a tertiary care hospital in rural India
• Thirunavukarasu M. R & Velmurugan A., International Journal
of Community Medicine and Public Health Thirunavukarasu MR
et al. Int J Community Med Public Health. 2018 Sep;5(9):3882-
3886 http://www.ijcmph.com , DOI:
http://dx.doi.org/10.18203/2394-6040.ijcmph20183421

PICO ANALYSIS
P I C O
50 Staff Nurses with
more than one year
experience
A pre-tested
questionnaire
covering socio-
demographic
information &
questions
regarding law and
ethics
No Comparison (78%) had inadequate
knowledge,
7% had moderate
knowledge and
4% were had adequate
knowledge regarding
law and ethics in
Nursing.
Need for increase in
awareness regarding
ethical issues
associated with
clinical practice &
research.

Evidence - 2
“Indian Nursing Council – It’s role in evolving and
administering paramedical professional ethics”
• S. P. Subashini., Santosh University Journal of Health Sciences,
Original Research Article DOI: 10.18231/2455-1732.2018.0010,
2018;4(1):41-44

PICO ANALYSIS
P I C O
1200 nurse
educators, final
year nursing
students and nurse
clinicians
A well-structured
questionnaire
schedule was
drafted with
demographic
variables and
assessment of
knowledge
on professional
ethics and role of
Indian
Nursing Council
No Comparison Nurse educators had
63.0%
adequate knowledge, final
year nursing students had
13.3% adequate
knowledge & nurse
clinicians had only 7.0%
adequate
knowledge.
Concludes that awareness
on ethical codes in nursing
curriculum & providing
continuing education will
optimize the high quality
nursing care, as nursing
profession faces legal issues
and challenges.

Dr. Dayanand B, Asst. Prof., Sumandeep
Nursing College, Sumandeep Vidyapeeth,
Vadodara

Dr. Dayanand B

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