Professional Roles in Nursing Practiceuserfiles/pdfs/course-materials/Legal...Professional Roles in...

Professional Roles in Professional Roles in Nursing Practice Nursing Practice Legal and Ethical Principles and Legal and Ethical Principles and

ValuesValues

IntroductionIntroduction

Professional nursing has expanded rapidly Professional nursing has expanded rapidly within the past few years to include increased within the past few years to include increased expertise, specialization, autonomy, and expertise, specialization, autonomy, and accountability from both legal and ethical accountability from both legal and ethical perspectives. Nurses must be informed of legal perspectives. Nurses must be informed of legal issues to stay current and within their scope of issues to stay current and within their scope of practice. practice.

Professional Nursing PracticeProfessional Nursing Practice

Nurse Practice ActNurse Practice ActThe single most important piece of legislation The single most important piece of legislation for nursing because it affects all facets of for nursing because it affects all facets of nursing practice. It is the law within the state nursing practice. It is the law within the state and state boards of nursing cannot grant and state boards of nursing cannot grant exceptions, waive the actexceptions, waive the act’’s provisions, or expand s provisions, or expand practice outside the actpractice outside the act’’s specific provisions. s specific provisions.

State Boards of NursingState Boards of Nursing

Established by Nurse Practice ActEstablished by Nurse Practice Act

Two main purposes Two main purposes -- Ensure enforcement of the act by serving Ensure enforcement of the act by serving regulate those who come under itsregulate those who come under itsprovisions and prevent those not provisions and prevent those not addressed within the act from practicingaddressed within the act from practicingnursing.nursing.

To protect the public, ensuring that thoseTo protect the public, ensuring that thosewho present themselves as nurses are who present themselves as nurses are licensed to practice within the state. licensed to practice within the state.

The National Council of State Boards of The National Council of State Boards of Nursing serves to further ensure that Nursing serves to further ensure that individual state actions against a nurseindividual state actions against a nurse’’s s license are recorded and enforced in alllicense are recorded and enforced in allstates in which the individual nurse holdsstates in which the individual nurse holdslicensure. licensure.

Grounds for Disciplinary ActionGrounds for Disciplinary Action

Is guilty of fraud or deceit in procuring or Is guilty of fraud or deceit in procuring or attempting to procure a license to attempting to procure a license to practice nursing.practice nursing.

-- forgery or alterationforgery or alteration-- licensure examlicensure exam-- prescribing without prescriptiveprescribing without prescriptive

authorityauthority


Is guilty of a crime or gross immoralityIs guilty of a crime or gross immorality-- conviction for any crimeconviction for any crime-- crossing boundariescrossing boundaries

Is unfit or incompetent by reason of Is unfit or incompetent by reason of negligence, habits, or other causesnegligence, habits, or other causes-- negligencenegligence-- gross negligencegross negligence-- physical and/or psychological impairmentphysical and/or psychological impairment


Is habitually intemperate or is addicted to Is habitually intemperate or is addicted to the use of habitthe use of habit--forming drugsforming drugs

Is mentally incompetentIs mentally incompetent-- requires an order from a judgerequires an order from a judge


Is guilty of unprofessional conductIs guilty of unprofessional conduct-- failing to assess and evaluate or failing failing to assess and evaluate or failing

to interveneto intervene

-- failing to report or documentfailing to report or document

-- failing to make entries, destroying failing to make entries, destroying entries, making false entriesentries, making false entries


Unprofessional conduct continuedUnprofessional conduct continued

-- unlawfully appropriatingunlawfully appropriating

-- failing to administer medications/failing to administer medications/treatments in a responsible mannertreatments in a responsible manner

-- performing/attempting to perform performing/attempting to perform procedures without trainingprocedures without training



-- violating confidentialityviolating confidentiality-- causing suffering, permitting or allowingcausing suffering, permitting or allowingphysical or emotional injuryphysical or emotional injury

-- abandonmentabandonment-- failing to report violations to the boardfailing to report violations to the board-- inappropriate delegationinappropriate delegation



-- failing to supervisefailing to supervise-- failing to conform to universal failing to conform to universal

precautionsprecautions-- acts of dishonestyacts of dishonesty-- failing to display insigniafailing to display insignia


Has had a license, certificate, or Has had a license, certificate, or registration revoked, suspended, or registration revoked, suspended, or placed on probation or under disciplinaryplaced on probation or under disciplinaryaction in any jurisdictionaction in any jurisdiction

Has voluntarily surrendered a license, Has voluntarily surrendered a license, certification, or registration and has not certification, or registration and has not been reinstated in any jurisdictionbeen reinstated in any jurisdiction


Has willfully or repeatedly violated any of Has willfully or repeatedly violated any of the provisions of this chapterthe provisions of this chapter-- continue action after ASBN noticecontinue action after ASBN notice-- disregard of License expiration datedisregard of License expiration date-- false, incorrect, or misleading false, incorrect, or misleading information regarding license statusinformation regarding license status

-- practice outside of Scope of Practicepractice outside of Scope of Practice-- failure to follow Nurse Practice Act/failure to follow Nurse Practice Act/rules and regulationsrules and regulations

NegligenceNegligence

Conduct that is lacking in care and typically Conduct that is lacking in care and typically concerns nonprofessionals. Many experts concerns nonprofessionals. Many experts equate negligence with carelessness, a deviation equate negligence with carelessness, a deviation from the standard of care that a reasonable and from the standard of care that a reasonable and prudent professional nurse would deliver under prudent professional nurse would deliver under similar circumstances.similar circumstances.

MalpracticeMalpractice

Referred to as professional negligence, concerns Referred to as professional negligence, concerns professional actions and is the failure of a professional actions and is the failure of a person with professional education and skills to person with professional education and skills to act in a reasonable and prudent manner. act in a reasonable and prudent manner.

MalpracticeMalpractice

The following six elements must be presented to The following six elements must be presented to have a successful malpractice suit. All of these have a successful malpractice suit. All of these factors must be proven before the court will find factors must be proven before the court will find liability against the nurse or institution. liability against the nurse or institution.

Elements of MalpracticeElements of Malpractice

Duty owed the patientDuty owed the patient-- Failure to monitor a patientFailure to monitor a patient’’s response tos response to

treatment. The more difficult to prove is treatment. The more difficult to prove is nature of the duty, which involves nature of the duty, which involves standard of care that represent thestandard of care that represent theminimum requirements for acceptableminimum requirements for acceptablepractice.practice.


Breech of the duty of care owed the patient.Breech of the duty of care owed the patient.

-- Once the standard of care is established,Once the standard of care is established,the breach or falling below the standard the breach or falling below the standard of care is easy to show.of care is easy to show.


ForeseeabilityForeseeability-- Involves the concept that certain eventsInvolves the concept that certain events

may be reasonably expected to causemay be reasonably expected to causespecific results. The nurse must havespecific results. The nurse must haveprior knowledge or information that failureprior knowledge or information that failureto meet a standard of care may resultto meet a standard of care may resultin harm.in harm.


CausationCausation-- The nurseThe nurse’’s actions or lack of actions s actions or lack of actions

directly caused the patientdirectly caused the patient’’s harm.s harm.

InjuryInjury-- The resultant injury must be physical, not The resultant injury must be physical, not

merely psychological or transient.merely psychological or transient.


DamagesDamages-- The injured party must be able to prove The injured party must be able to prove

damages. They must prove financial damages. They must prove financial harm. harm.

LiabilityLiability

Personal liability Personal liability –– defines each persondefines each person’’ssresponsibility and accountability for responsibility and accountability for individual actions or omissions.individual actions or omissions.

Vicarious liability Vicarious liability –– imputation of accountability imputation of accountability upon one person or entity for the actions of upon one person or entity for the actions of another person; substituted or imputed liability.another person; substituted or imputed liability.

LiabilityLiability

Corporate Liability Corporate Liability –– holds that the institution holds that the institution has the responsibility and accountability for has the responsibility and accountability for maintaining an environment that ensures quality maintaining an environment that ensures quality healthcare delivery for consumers.healthcare delivery for consumers.

Causes of Malpractice for Nurse Causes of Malpractice for Nurse ManagersManagers

Nurse managers are charged with maintaining a Nurse managers are charged with maintaining a standard of competent nursing care within the standard of competent nursing care within the institution.institution.


Delegation and SupervisionDelegation and Supervision

The nurse manager retains personal liability for the The nurse manager retains personal liability for the reasonable exercise of the delegation and reasonable exercise of the delegation and supervision activities. The failure to delegate supervision activities. The failure to delegate within acceptable standards of professional within acceptable standards of professional nursing practice may constitute malpractice. nursing practice may constitute malpractice.


Duty to Orient, Educate and EvaluateDuty to Orient, Educate and Evaluate

Nurse managers are responsible for the daily Nurse managers are responsible for the daily evaluation of whether nurses are performing evaluation of whether nurses are performing competent care. They must ensure that they competent care. They must ensure that they promptly respond to all allegations of promptly respond to all allegations of incompetent or questionable nursing care. incompetent or questionable nursing care.

Cause for Malpractice for Nurse Cause for Malpractice for Nurse ManagersManagers

Failure to WarnFailure to WarnNewer area of potential liability for nurse Newer area of potential liability for nurse

managers that involves the responsibility to managers that involves the responsibility to warn subsequent or potential employees of warn subsequent or potential employees of nursesnurses’’ incompetence or impairment.incompetence or impairment.


Staffing issuesStaffing issues-- Adequate numbers of staff members at a time Adequate numbers of staff members at a time of advancing patient acuity and limited of advancing patient acuity and limited resources. Nurse managers must do everything resources. Nurse managers must do everything in her power to provide adequate staff, and if in her power to provide adequate staff, and if he/she is not able then they have legal duty to he/she is not able then they have legal duty to notify proper chain of command when notify proper chain of command when understaffing endangers patient welfare.understaffing endangers patient welfare.

Cause of Malpractice for Nurse Cause of Malpractice for Nurse MangersMangers

Floating staff from one unit to another. Must Floating staff from one unit to another. Must consider area of staffconsider area of staff’’s expertise and send to s expertise and send to comparable unit.comparable unit.

Temporary or agency staff to augment hospital Temporary or agency staff to augment hospital staffing staffing –– should be given a brief but thorough should be given a brief but thorough orientation to institution policies and orientation to institution policies and procedures, etc. procedures, etc.

Protective and Reporting LawsProtective and Reporting Laws

Ensures the safety or rights of specific classes of Ensures the safety or rights of specific classes of individuals. Most states have reporting laws for individuals. Most states have reporting laws for suspected child and older adult abuse and laws suspected child and older adult abuse and laws for reporting certain categories of diseases and for reporting certain categories of diseases and injuries.injuries.

Informed ConsentInformed Consent

The authorization by the patient or the patientThe authorization by the patient or the patient’’s s legal representative to do something to the legal representative to do something to the patient. Inherent in the doctrine of informed patient. Inherent in the doctrine of informed consent is the right of the patient to informed consent is the right of the patient to informed refusal. Patients must clearly understand the refusal. Patients must clearly understand the possible consequences of their refusal.possible consequences of their refusal.

Informed Consent ContinuedInformed Consent Continued

Legal capacity Legal capacity -- the first requirement and is the first requirement and is determined by age and competency. determined by age and competency. Competency involves the ability to understand Competency involves the ability to understand the consequences of actions or the ability to the consequences of actions or the ability to handle personal affairs. Emancipated minors handle personal affairs. Emancipated minors are minors seeking treatment for substance are minors seeking treatment for substance abuse, communicable diseases and pregnant abuse, communicable diseases and pregnant minors. minors.

Informed Consent ContinuedInformed Consent Continued

Voluntary action Voluntary action -- means the patient was not means the patient was not coerced by fraud, duress, or deceit into allowing coerced by fraud, duress, or deceit into allowing the procedure or treatment.the procedure or treatment.

Comprehension Comprehension –– the patients must be given the patients must be given sufficient information, in terms he or she can sufficient information, in terms he or she can reasonable be expected to comprehend. reasonable be expected to comprehend.

Privacy and ConfidentialityPrivacy and Confidentiality

The patients right to protection against The patients right to protection against unreasonable and unwarranted interference with unreasonable and unwarranted interference with the patientthe patient’’s solitude, and the right to privacy of s solitude, and the right to privacy of the medical record.the medical record.

HIPAAHIPAA

Policies and ProceduresPolicies and Procedures

Written policies and procedures are a Written policies and procedures are a requirement of JCAHO. These documents set requirement of JCAHO. These documents set standards for care for the institution and direct standards for care for the institution and direct practice. They must be clearly stated, well practice. They must be clearly stated, well delineated, and based on current practice. There delineated, and based on current practice. There must be a copy available to staff on each unit. must be a copy available to staff on each unit.

Professional Nursing Practice: Professional Nursing Practice: EthicsEthics

Ethics TheoriesEthics Theories-- Deontological TheoriesDeontological Theories--from the Greek from the Greek

word word ““dutyduty””, derived rules and norms for , derived rules and norms for the duties that human beings owe one the duties that human beings owe one another by virtue of commitments madeanother by virtue of commitments madeand roles assumed; has sometimes and roles assumed; has sometimes been subdivided into situational ethicalbeen subdivided into situational ethicaltheory. theory.


Ethics Theories continuedEthics Theories continued-- Teleological theoriesTeleological theories--from the Greek word from the Greek word

““endend””, derived norms and rules for conduct, derived norms and rules for conductfrom the consequences of actions.from the consequences of actions.

-- PrinciplismPrinciplism-- emerging theory of ethics that emerging theory of ethics that incorporates existing ethical principles and incorporates existing ethical principles and attempts to resolve conflicts by applying oneattempts to resolve conflicts by applying oneor more of the ethical principles. or more of the ethical principles.


Ethical PrinciplesEthical Principles-- AutonomyAutonomy--personal freedom and the rightpersonal freedom and the right

to choose what will happen to oneto choose what will happen to one’’s owns ownperson.person.

-- BeneficenceBeneficence--principle that states that theprinciple that states that theaction one takes should promote good.action one takes should promote good.

-- Nonmaleficence Nonmaleficence –– states that one should dostates that one should dono harmno harm


Ethical principles continuedEthical principles continued-- VeracityVeracity-- principle that compels the truth is principle that compels the truth is

told completely.told completely.-- JusticeJustice-- principle that all persons should beprinciple that all persons should be

treated equally and fairly.treated equally and fairly.-- Paternalism Paternalism –– principle that allows one to principle that allows one to

make decisions for another.make decisions for another.


Ethical principles continuedEthical principles continued-- Fidelity Fidelity –– keeping onekeeping one’’s promises or s promises or

commitments.commitments.-- Respect for others Respect for others –– the highest ethical the highest ethical

principle, respect for others acknowledgesprinciple, respect for others acknowledgesthe right of individuals to make decisions and the right of individuals to make decisions and live by those choices. live by those choices.


Ethical decisionEthical decision--making involves reflectionmaking involves reflectionon the following: on the following:

-- who should make the choicewho should make the choice-- possible options or courses of actionpossible options or courses of action-- available optionsavailable options-- consequences, both good and badconsequences, both good and bad-- rules, obligations, and values that shouldrules, obligations, and values that should

direct choicesdirect choices--desired goals or outcomesdesired goals or outcomes


Ethical DecisionEthical Decision--making contmaking cont’’d.d.

Nurses need to combine all of these elementsNurses need to combine all of these elementsusing an orderly, systematic and objectiveusing an orderly, systematic and objectivemethod. Ethical decisionmethod. Ethical decision--making models making models assist in accomplishing this goal.assist in accomplishing this goal.


MORAL Model for Ethical Decision MakingMORAL Model for Ethical Decision Making

M M –– Massage the dilemma. Identify and defineMassage the dilemma. Identify and definethe issues in the dilemma. Consider the the issues in the dilemma. Consider the

options of all the major players in theoptions of all the major players in thedilemma and their value systems. This dilemma and their value systems. This includes patients, family members, nurses,includes patients, family members, nurses,physicians, clergy, and any other interphysicians, clergy, and any other inter--disciplinary healthcare members.disciplinary healthcare members.


MORAL Model contMORAL Model cont’’dd

O O –– Outline the options. Examine all the Outline the options. Examine all the options, including those that are lessoptions, including those that are lessrealistic and conflicting. This stage isrealistic and conflicting. This stage isdesigned only for considering optionsdesigned only for considering optionsand not for making a final decision.and not for making a final decision.



R R –– Resolve the dilemma. Review the issuesResolve the dilemma. Review the issuesand options, applying basic principles ofand options, applying basic principles ofethics to each option. Decide the best ethics to each option. Decide the best option based on the views of al thoseoption based on the views of al thoseconcerned in the dilemma. concerned in the dilemma.



A A –– Act by applying the chosen option. ThisAct by applying the chosen option. Thisstep is usually the most difficult becausestep is usually the most difficult becauseit requires actual implementation, whereasit requires actual implementation, whereasthe previous steps allow only for dialoguethe previous steps allow only for dialogueand discussion.and discussion.



L L –– Look back and evaluate the entire process,Look back and evaluate the entire process,including the implementation. No processincluding the implementation. No processis complete without a thorough evaluation.is complete without a thorough evaluation.Ensure that those involved are able to Ensure that those involved are able to follow through on the final option. If not,follow through on the final option. If not,a second decision may be required and thea second decision may be required and theprocess must start again at the initial step.process must start again at the initial step.


Ethics committeesEthics committeesProvide structure and guidelines for potentialProvide structure and guidelines for potentialproblems and can provide short term and long problems and can provide short term and long term assistance. They also serve as open forumsterm assistance. They also serve as open forumsfor discussion and function as true patientfor discussion and function as true patientadvocates by placing the patient at the core of advocates by placing the patient at the core of the committee discussions.the committee discussions.

Future Ethical Concerns for NursesFuture Ethical Concerns for Nurses

Autonomy and independent practice among Autonomy and independent practice among nurses.nurses.Quality of care in home and community Quality of care in home and community settings.settings.Development of nurses as leaders in the healthDevelopment of nurses as leaders in the health--care delivery field.care delivery field.PatientPatient’’s refusal of healthcares refusal of healthcareIssues of death and dyingIssues of death and dying

Future Ethical Concerns for NursesFuture Ethical Concerns for Nurses

NursesNurses’’ ability to be patient advocates in todayability to be patient advocates in today’’s s healthcare structure.healthcare structure.The ability to perform competent, quality The ability to perform competent, quality nursing care in a system that rewards only costnursing care in a system that rewards only cost--saving measures and that employs increasingly saving measures and that employs increasingly fewer professional nurses. fewer professional nurses.

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