LEGAL AND ETHICAL ISSUES IN MATERNAL-NEWBORN NURSING AND WOMENS HEALTH

Introduction

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Legal and Ethical Issues in Maternal/Newborn and Womens Health

Developed by

D. Ann Currie,R.N.,M.S.N.

2012

LEGAL CONSIDERATIONS

GENERAL LEGAL CONCEPTS

ARENAS FOR CONSIDERATION

LITIGATION

RISK MANAGEMENT

QUALITY ASSURANCE

DOCUMENTATION

CLINCAL EXAMPLES OF COMMON LEGAL ISSUES

GENERAL LEGAL CONCEPTS

LAW CAN BE DEFINED ASTHOSE RULES MADE BY HUMANS WHICH REGULATE SOCIAL CONDUCT IN A FORMALLY PRESCRIBED AND LEGALLY BINDING MANNER.(BERNZWEIG)

FUNCTIONS OF THE LAW IN NURSING

THE LAW SERVES A NUMBER OF FUNCTIONS IN NURSING:

IT PROVIDES A FRAMEWORK FOR ESTABLISHING WHICH NURSING ACTIONS IN THE CARE OF THE CLIENTS ARE LEGAL

IT DIFFERENTIATES THE NURSESRESPONSIBILITIES FROM THOSE OF OTHER HEALTH PROFESSIONAL

CONT. FUNCTIONS

IT HELPS ESTABLISH THE BOUNDARIES OF INDEPENDENT NURSING ACTION.

IT ASSISTS IN MAINTAINING A STANDARD OF NURSING PRACTICE BY MAKING NURSES ACCOUNTABLE UNDER THE LAW.

SOURCES OF LAW

CONSTITUTION

LEGISLATION (STATUTES)

COMMON LAW

TYPES OF LAWS

PUBLIC LAW- CRIMINAL LAW

PRIVATE LAW-CIVIL LAW

CONTRACT LAW

TORT LAW

ARENAS OF LEGAL CONSIDERATION

PERSONAL PROFESSIONAL PRACTICE

CLIENT CARE AND ADVOCACY

LEGAL CONSIDERATIONS IN PERSONAL PROFESSIONAL PRACTICE

SCOPE OF PRACTICE

STANDARDS OF CARE

LICENSURE

COLLECTIVE BARGAINING

SCOPE OF PRACTICE

THE NURSE PRACTICE ACT----

BROAD DEFINITION OF PERMISSIBLE BOUNDARIES OF PRACTICE WITHIN A STATE.

DISTINGUISHES NURSING PRACTICE FROM THE PRACTICE OF OTHER HEALTH PROFESSIONALS

SCOPE OF PRACTICE

EXCLUDES UNTRAINED OR UNLICENSED INDIVIDUALS FROM PRACTICING NURSING.

RULES AND REGULATIONS PROMULGATED BY STATE BOARDS OF NURSING PROVIDE OFFICIAL INTERPRETATION OF NURSING ACTS.

SCOPE OF PRACTICE

CORRECT INTERPRETATION AND UNDERSTANDING OF STATE PRACTICE ACTS ENABLES THE NURSE: TO PROVIDE SAFE CARE WITHIN THE LIMITS OF NURSING PRACTICE AND TO AVOID THE RISK OF BEING ACCUSED OF PRACTICING MEDICINE WITHOUT A LICENSE

READ AND KNOW THE NURSE PRACTICE ACT ****.

STANDARDS OF CARE

DEFINITION:

MINIMUM CRITERIA FOR COMPETENT,PROFICIENT DELIVERY OF NURSING CARE.

USED TO EVALUATE THE QUALITY OF CARE PROVIDED

FORMULATED FROM SKILLS AND KNOWLEDGE COMMONLY POSSESSED BY MEMBERS OF

CONT.

A PROFESSION.NURSES.

IDENTIFY HEALTH,DEMOGRAPHIC,ENIRONMENTAL,AND PSYCHOSOCIAL PARAMETERS OF CARE

REFLECTS CURRENT KNOWLEDGE IN THE FIELD,AND,THEREFORE,ARE DYNAMIC AND SUBJECT TO CHANGE.

USES OF STANDARDS OF CARE

CRITERION FOR DETERMINING IF A NURSE HAS VIOLATED THE STATE -NURSE PRACTICE ACT.

CRITERION FOR DETERMINING IF A NURSE HAS VIOLATED STATE OR CITY CRIMINAL CODES

CRITERION ELEVATING NURSING PRACTICE TO A PROFESSIONAL LEVEL.

INTERNAL STANDARDS OF CARE

INDIVDUAL

INSTITUTIONAL

SET BY ROLE AND EDUCATION OF THE NURSE: JOB DESCRIPTION,EDUCATION,AND EXPERTISE

SET BY INDIVIDUAL INSTITUTIONS: POLICIES AND PROCEDURES.

EXTERNAL OR NATIONAL STANDARDS OF CARE

EXTERNAL BECAUSE THEY SUPERCEDE INDIVIDUAL PRACTITIONERS AND INSTITUTIONS.

BROADER THAN LOCALITY RULES: STANDARDS OF CARE VEIWED FROM THE PERSPECTIVE OF CARE WITHIN A GEOGRAPHIC AREA.

CONT. EXTERNAL STANDARDS OF CARE

BASED ON REASONABLENESS AND AVERAGE DEGREE OF SKILL,CARE, AND DILIGENCE PRACTICED BY MEMBERS OF THE PROFESSION ACROSS THE NATION.

NURSES IN A VARIETY OF SETTINGS AND LOCALS MUST MEET THE SAME STANDARDS: HOMES,BIRTHING CENTERS,HOSPITALS ETC.

CONT. ETERNAL STANDARDS OF CARE

STANDARDS ESTABLISHED BY:

STATE BOARDS OF NURSING THROUGH NURSE PRACTCE ACTS OR PROMULGATED RULES AND REGULATIONS.

PROFESSIOAL ORGANIZATIONS: ANA,ICN,OR CONGRESS FOR NURSING PRACTICE.

CONT. EXTERNAL STANDARDS OF CARE

SPECIALITY NURSING ORGANIZATIONS:AWHONN,NANN, ACNM.

FEDERAL ORGANIZATIONS AND GUIDELINE: JCAHO AND MEDICARE RULES.

STANDARD OF CARE NEGLIGENCE AND MALPRACTICE

NEGLIGENCE- IT IS OMITTING AN ACT OR DEVIATION FROM THE STANDARD OF CARE THAT A REASONABLY PRUDENT PERSON WOULD NOT OMIT OR COMMIT UNDER SIMILAR CIRCUMSTANCES.

MALPRACTICE- IT IS A NEGLIGENT ACTION OF A PROFESSIONAL

ELEMENTS OF NEGLIGENCE

THERE WAS A DUTY TO PROVIDE CARE.

THE DUTY WAS BREACHED.

INJURY OCCURRED.

THE BREACH OF DUTY CAUSED INJURY

EXAMPLES OF NEGLIGENCE

EXAMPLES OF OMISSION: FAILING TO GIVE A MEDICATION, FAILING TO ASSESS PROPERLY,FAILING TO NOTIFY A PHYSICIAN OF A CHANGE IN A CLIENTS CONDITION OR STAUS.

EXAMPLES OF COMMISSION:GIVING WRONG MEDICATION OR TO WRONG CLIENT

CONT.

PLACING INFANT IN WRONG CRIB OR GIVING INFANT TO WRONG MOTHER.

CONT.

NURSES NOT MEETING APPROPRIATE STANDARDS OF CARE COULD BE SUBJECT TO ALEGATIONS OF NEGLIGENCE OR MALPRACTICE.

NURSES RESPONSILITY IN PREVENTING NEGLIGENCE AND MALPRACTICE

OBTAIN AND MAINTAIN CURRENT INFORMATION REGARDING THE STATE NURSE PRACTICE ACT- GET A COPY AND READ IT AND KNOW IT..READ PUBLICATION FROM THE STATE (BON), VISIT WEB SITE FOR BON INFORMATION AND ATTEND BON WORKSHOPS.

CONT. NURSE RESPONSIBLITY

OBTAIN AND MAINTAIN CURRENT INFORMATION ON INTERNAL AND EXTERNAL STANDARDS OF PRACTICE,

SEEK CONTINUING EDUCATION TO REMAIN CURRENT IN SPECALITY AREAS

USE THE NURSING PROCESS WHEN GIVING CLIENT CARE.

CONT. NURSES RESPONSIBILITY

DEVELOPE A POSITIVE, EMPOWERING RELATIONSHIP WITH CLIENTS---SEE CLIENTS AS AN IMPORTANT MEMBER OF THE HEALTH TEAM.

BE THROUGH IN COMPLETING AND REPORTING ASSESSMENTS AND IMPLEMENTING CARE.

CONT NURSES RESPONSIBLITY

MAINTAIN CLEAR, CONCISE, ACCURATE, COMPLETE, AND LEDGIBLE DOCUMENTATION.

QUESTION APPROPRIATENESS OF CARE WHEN HARM CAN BE DONE TO CLIENT.

CHECK MEDICAL ORDERS FREQUENTLY.

USE CHAIN OF COMMAND.

LEGAL CONSIDERATIONS FOR CLIENT CARE

HEALTHCARE REFORM

MANAGED CARE

SHORTENED HOSPITAL STAYS

UNLICENSED ASSISTIVE PERSONNNEL(UAP)

NURSES ROLE AS CLIENT ADVOCATE.

Healthcare reform

The USA leads the world in healthcare spending, yet has one of the highest infant mortality rates among the industrialized nations..

One of the primary factors related to infant mortality(deaths under one year of age per 1000 live births) is an increase in the delivery of low birth weight infants, which is linked to lack of prenatal care.

Healthcare Reform

Barriers to access to prenatal care

1) Costs of health care

2) Limited financial resources

3)Uncoordinated service systems

4) Individual behaviors and beliefs concerning health care

5)Bureaucratic obstacles, such as complicated, lengthy forms for Medicaid

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HEALTHCARE REFORM

Barriers to prenatal care

6) Unavailability of maternal services in certain parts of the country

7) Underfunded and overcrowded publicly supervised clinics

8) Difficulty in recruiting and retaining healthcare providers in publicly subsidized clinics

Healthcare reform

Barriers to prenatal care

9) Lack of coordinated services for needy individuals

10) Inaccessibility to prenatal services because of transportation, location, and lack of child care facilities.

11) Other.

HEALTHCARE REFORM

Federal and state governments, through policies and legislation, have begun to implement strategies to resolve these barriers by:

1) Broadening health insurance coverage for childbearing women and infants

2) Improving coordination and funding of public programs

Healthcare Reforms

3) Simplifying bureaucratic procedures

4) Increasing the number of maternity care providers

5) Establishing a national council on children and health

6) Raising public awareness throughout the country

7) Other..

HEALTHCARE REFORM

NEED TO CONTINUE to seek reform to further control costs, improve access to healthcare, and improve quality of healthcare

MANAGED CARE

Private sector solution for decreasing healthcare costs

1) Health insurance plans that combine: delivery of healthcare services, financing of those services, controlling the use of services.

2) Philosophy of managed care organizations includes:

Managed Care

Cont. Health promotion and disease prevention, desire to avoid serious disease and costly treatment services

3)To meet expenses and make a reasonable profits

4) Creates a climate in which providers have: little time and few resources with which to provide care and financial

MANAGED CARE

CONT. -DISINCENTIVES FOR PROVIDERS TO GIVE ADEQUATE SERVICES TO THEIR CLIENTS.

5) CONSEQUENCES : FEWER EXPENSIVE TESTS OR COSTLY PROCEDURS PERFORMED, SHORTENED HOSPITAL STAYS AND INCREASED USE OF UNLICENSED HEALTHCARE WORKERS.

SHORTENED HOSPITAL STAYS

During the early to mid-1990 hospital stays after birth were shortened to 24 hours or less.

Consequently, there was not enough time for maternal and parental teaching regarding self care and infant care- problems in infant care and health developed, breast-feeding problems, and self care problems in the mothers.

SHORTENED HOSPITAL STAYS

Several states passed laws requiring longer stays for maternity and neonatal clients..

U.S. Congress passed Senate Bill 969, the Newborns and Mothers Protection Act of 1996:1) Set a national standard requiring health insurance and employer-provided benefit plans to cover minimum hospital stay: 48hrs-vaginal delivery,

SHORTENED HOSPITAL STAYS

96 hrs for c/s, early discharge with home health care..within 24-72 hrs of discharge.

2) Even with federal law mandating a longer postpartum stay, nurses are still responsible for: verbal and written instructions about infant and self-care, and s/s indicating problems and what to do, and f/u visit.

In Texas nurses must teach about PP depression

SHORTENED HOSPITAL STAYS

Cont. evaluation of parents learning, recommending timely follow-up care, incliding a home visit,whenmom seems at risk after a longer stay.

UNLICENSED ASSISTIVE PERSONNEL (UAP)

UAPs are healthcare workers who have no defined body of knowledge or educational preparation upon which to base their practice

Uncreditentialed

No state or federal regulatory body to validate their competence

UAPS

Nurses are responsible for the delegation of tasks to UAPssee Texas BON guidelines for delegation .

UAPs can perform repetitive taskswhich are clearly defined and for which they have been trained.

Nurses should obtain information on UAPs training and skills prior to delegating tasks.

UAPS

Inappropriate delegation to UAPs increases the nurses liability and may jeopardize the nurses license.

What should not be delegated to UAPs: Essential nursing processes of assessing,diagnosing of a problem, planning client care, implementing that care, and evaluating the outcomes.And judgements about client status.

NURSES ROLE AS CLIENT ADVOCATE

Maintain current information about issues critical to client care.

Educate clients and other significant persons about such issues

Become involved in the political process as an advocate for quality healthcare for all healthcare recipients.

Other...

LITIGATION

Statues of limitations:

Maternal or Women Health Care Patients-

2 years

Neonate/Infant-

Majority plus 2years- Texas Majority is 18years old plus 2year= 20 years

LITIGATION

What to do if you receive a notice you are being sued

Do not panic

Talk and hire a your own lawyer. Dont talk to anyone except your lawyer. You may have to talk to your employers lawyer/s. But talk to your lawyer first.

You must notify the Texas BON

Do not lie, change chart, or talk too much

Follow your lawyers advise.

RISK MANGEMENT

It is to help improve the patient-care and /or environment of the hospital or organization and safety of patients, visitors, and/or employee.

Incident/Variance reports do not chart in Nursing Notes you did one

QUALITY IMPROVEMENT

A System to Improve Patient Care

Examples of QI in Maternal/Newborn Care and Womens Health Care Areas.

ID of mother/baby couplet.

Documentation of Pain Management

Nurse to Nurse Reports or handoff

Time out prior to Cesarean sections or Bilateral Tubal Ligations

DOCUMENTATION

A nurses best friend or worst nightmare.

What is important in Nursing Documentation

Good spelling and grammar

Clear, Concise, and Complete

Facts and Data

Use the Systematic problem solving process

(Nursing Process), know and use Standards of Care, and legal requirements.

CLINICAL EXAMPLES OF LEGAL ISSUES

Oxytocin administration

Nonreassuring Fetal Heart Rate Patterns

Bad patient outcomes for patients-mother, baby, or woman.

Other.

ETHICAL CONSIDERATIONS

ETHICS IS BASED ON A RESPONSIBILITY OR DUTY MODEL EXAMINING WHAT OUR BEHAVIOR OUGHT TO BE IN RELATION TO OURSELVES, OTHER HUMAN BEINGS,AND THE ENVIRONMENT

ETHICS

ETHICS INCORPORATES FACTORS SUCH AS: RISKS.BENEFITS,OTHER RELATIONSHIPS, CONCERNS, AND THE NEEDS AND ABILITIES OF PERSONS AFFECTED BY AND AFFECTING DECISIONS.

IT IS SUBJECT TO PHILOSOPHICAL, MORAL, AND INDIVIDUAL INTERPRETATIONS.

ETHICAL PRINCIPLES

SHOULD BE USE IN CLINICAL PRACTICE

RESPECT

AUTONOMY

BENEFICENCE

NONMALEFICENCE

VERACITY: DUTY TO TELL THE TRUTH

CONT. ETHICAL PRINCIPLES

FIDELITY: DUTY TO KEEP ONES PROMISE

JUSTICE

CONFIDENTIALITY

INFORMED CONSENT

UNIVERSALITY

ETHICAL DECISION-MAKING FRAMEWORK

MORAL

M:ESSAGE THE DILEMMA

O:OUTLINE THE OPTIONS

R:RESOLVE THE DILEMMA

A:ACT BY APPLYING THE CHOSEN OPTION

L:LOOK BACK AND EVALUATE THE ENTIRE PROCESS

MORAL

M: MESSAGE THE DILEMMA

IDENTIFY AND DEFINE ISSUES IN THE DILEMMA

DETERMINE WHO OWNS THE PROBLEM,THE INFORMATION,THE DECISION, AND THE CONSEQUENCES OF IT.

CONT. M

ESTABLISH THE FACTS AS BEST AS POSSIBLE.

CONSIDER THE OPTIONS,VALUES, AND MORAL POSITION OF THE MAJOR PLAYERS.

IDENTIFY VALUE CONFLICTS.

O: OUTLINE THE OPTIONS

EXAMINE ALL OPTIONS FULLY,INCLUDING THE LESS REALISTIC AND CONFLICTING ONES

IDENTIFY PROS AND CONS OF ALL THE OPTIONS

FULLY COMPREHEND THE OPTIONS AND ALTERATIVES AVAILABLE/

R: RESOLVE THE DILEMMA

REVIEW THE ISSUES AND OPTIONS

APPLY ETHICAL PRINCIPLES TO EACH OPTION

DECIDE THE BEST OPTION FOR ACTION ON THE VIEWS OF ALL THOSE CONCERNED

A: ACT BY APPLYING THE CHOSEN OPTION

IMPLEMENT THE CHOSEN OPTION

L: LOOK BACK AND EVALUATE THE ENTIRE PROCESS

INCLUDING IMPLEMENTATION.

ENSURE THAT ALL THOSE INVOLVED ARE ABLE TO FOLLOW THROUGH ON THE FINAL OPTION

REVISE THE DECISION AS INDICATED,STARTING THE PROCESS WITH THE INITIAL STEP.

WHERE TO GET HELP TO MAKE AN ETHICAL DECISION.

Ethics committee in your organizationhospital.

Clergy

Ethics depart.

Text...

ETHICAL CONSIDERATIONS IN MATERNITY NURSING

ASSISTED REPRODUCTION

ABORTION

FETAL OR EMBRYO RESEACH

CORD BLOOD BANKING

THE HUMAN GENOME PROJECT

GENETIC COUNSELING

FETAL RIGHTS VERSUS MATERNAL RIGHTS

NURSES RESPONSPONSIBLITIES

Learn to anticipate ethical dilemmas

Identify attitudes,values, and beliefs about ethical dilemmas taking into consideration the influence of cultural,religious, and social factors on the development of values.

Recognize the influence personal values have on care provided for clients by engaging in self-values clarification activities.

NURSESRESPONSIBILTIES

Review and update theoretical bases: gather current information on technological advances and changing trends in maternity nursing, review ethical principles and practice codes in regard to new technology and trends, become familiar with the clients knowledge base by reading lay literature related to maternity and neonatal advances

NURSES RESPONSIBILTIES

Attend cont. ed. Programs related to ethical issues and decision making-- participate in ethics committees with other healthcare professionals and inservice peers on ethical issues and decision making.

Review research journals regarding current trends in ethical decision making .comparing and contrasting the results with what is occurring in the clinical practice.

NURSES RESPONSIBILITES

Evaluate current social norms by following social,legal,religious, and political debates that may influence clinical decision making and quality care for clients experiencing dilemmas in the maternal, neontal, or womens health areas.

Avoid judgements about the life decisions of others.

NURSESS RESPONSIBILITIES

Aim to accept the values of others and their decisions regarding issues and provisions of care.

Dont allow personal beliefs and values to interfere with provision of quality care.

Understand the legal implications of the issues

Develop appropriate strategies for ethical decision making.

QUESTIONS

THANK YOU

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