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

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Professional Roles in

Nursing Practice

Legal and Ethical Principles and Legal and Ethical Principles and

Values Values

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Introduction

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.

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Professional Nursing Practice

Nurse Practice Act Nurse Practice Act

The 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 act

exceptions, waive the act’’s provisions, or expand s provisions, or expand practice outside the act

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State 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 its

regulate those who come under its

provisions and prevent those not

addressed within the act from practicing

nursing.

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To protect the public, ensuring that thoseTo protect the public, ensuring that those

who present themselves as nurses are who present themselves as nurses are

licensed to practice within the state. licensed to practice within the state.

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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 nurse individual state actions against a nurse’’s s

license are recorded and enforced in all license are recorded and enforced in all

states in which the individual nurse holds states in which the individual nurse holds

licensure. licensure.

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Grounds 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 authority

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Grounds for Disciplinary Action

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 causes

negligence, habits, or other causes

-- negligencenegligence

-- gross negligencegross negligence

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Grounds for Disciplinary Action

Is habitually intemperate or is addicted to Is habitually intemperate or is addicted to

the use of habit

the use of habit--forming drugsforming drugs

Is mentally incompetentIs mentally incompetent

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Grounds for Disciplinary Action

Is guilty of unprofessional conductIs guilty of unprofessional conduct

-- failing to assess and evaluate or failing failing to assess and evaluate or failing to intervene

to intervene

-- failing to report or documentfailing to report or document

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

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Grounds for Disciplinary Action

Unprofessional conduct continuedUnprofessional conduct continued

-- unlawfully appropriatingunlawfully appropriating

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

treatments in a responsible manner

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

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Grounds for Disciplinary Action

-- violating confidentialityviolating confidentiality

-- causing suffering, permitting or allowingcausing suffering, permitting or allowing physical or emotional injury

physical or emotional injury

-- abandonmentabandonment

-- failing to report violations to the boardfailing to report violations to the board

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Grounds for Disciplinary Action

-- failing to supervisefailing to supervise

-- failing to conform to universal failing to conform to universal precautions

precautions

-- acts of dishonestyacts of dishonesty

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Grounds for Disciplinary Action

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 disciplinary placed on probation or under disciplinary

action in any jurisdiction action 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 jurisdiction been reinstated in any jurisdiction

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Grounds for Disciplinary Action

Has willfully or repeatedly violated any of Has willfully or repeatedly violated any of

the 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 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 regulations

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Negligence

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.

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Malpractice

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.

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Malpractice

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.

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Elements 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 the standard of care that represent the

minimum requirements for acceptable minimum requirements for acceptable

practice. practice.

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Elements of Malpractice

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.

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Elements of Malpractice

ForeseeabilityForeseeability

-- Involves the concept that certain eventsInvolves the concept that certain events may be reasonably expected to cause

may be reasonably expected to cause specific results. The nurse must have specific results. The nurse must have

prior knowledge or information that failure prior knowledge or information that failure

to meet a standard of care may result to meet a standard of care may result

in harm. in harm.

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Elements of Malpractice

CausationCausation

-- The nurseThe nurse’’s actions or lack of actions s actions or lack of actions directly caused the patient

directly 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.

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Elements of Malpractice

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.

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Liability

Personal liability Personal liability –– defines each persondefines each person’’ss

responsibility 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.

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Liability

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.

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Causes of Malpractice for Nurse

Managers

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.

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Causes of Malpractice for Nurse

Managers

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.

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Causes of Malpractice for Nurse

Managers

Duty to Orient, Educate and Evaluate Duty 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.

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Cause for Malpractice for Nurse

Managers

Failure to Warn Failure to Warn

Newer 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

nurses

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Causes of Malpractice for Nurse

Managers

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.

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Cause of Malpractice for Nurse

Mangers

Floating staff from one unit to another. Must Floating staff from one unit to another. Must

consider area of staff

consider 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.

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Protective 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.

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Informed Consent

The authorization by the patient or the patient The 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.

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Informed 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.

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Informed 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.

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Privacy 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 patient

the patient’s solitude, and the right to privacy of ’s solitude, and the right to privacy of the medical record.

the medical record.

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Policies 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.

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Professional Nursing Practice:

Ethics

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 made another by virtue of commitments made

and roles assumed; has sometimes and roles assumed; has sometimes

been subdivided into situational ethical been subdivided into situational ethical

theory. theory.

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Professional Nursing Practice:

Ethics

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 conduct from 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 one attempts to resolve conflicts by applying one

or more of the ethical principles. or more of the ethical principles.

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Professional Nursing Practice:

Ethics

Ethical PrinciplesEthical Principles

-- AutonomyAutonomy--personal freedom and the rightpersonal freedom and the right to choose what will happen to one

to choose what will happen to one’’s owns own person.

person.

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

-- Nonmaleficence Nonmaleficence –– states that one should dostates that one should do no harm

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Professional Nursing Practice:

Ethics

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.

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Professional Nursing Practice:

Ethics

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 acknowledges principle, respect for others acknowledges

the right of individuals to make decisions and the right of individuals to make decisions and

live by those choices. live by those choices.

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Professional Nursing Practice:

Ethics

Ethical decisionEthical decision--making involves reflectionmaking involves reflection

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 choices

direct choices

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Professional Nursing Practice:

Ethics

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

Nurses need to combine all of these elements Nurses need to combine all of these elements

using an orderly, systematic and objective using an orderly, systematic and objective

method. Ethical decision

method. Ethical decision--making models making models assist in accomplishing this goal.

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Professional Nursing Practice:

Ethics

MORAL Model for Ethical Decision MakingMORAL Model for Ethical Decision Making

M

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

the issues in the dilemma. Consider the

options of all the major players in the

dilemma and their value systems. This

includes patients, family members, nurses,

physicians, clergy, and any other inter

physicians, clergy, and any other inter- -disciplinary healthcare members.

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Professional Nursing Practice:

Ethics

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 less options, including those that are less

realistic and conflicting. This stage is realistic and conflicting. This stage is designed only for considering options designed only for considering options

and not for making a final decision. and not for making a final decision.

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Professional Nursing Practice:

Ethics

R

R –– Resolve the dilemma. Review the issuesResolve the dilemma. Review the issues and options, applying basic principles of and options, applying basic principles of

ethics to each option. Decide the best ethics to each option. Decide the best

option based on the views of al those option based on the views of al those

concerned in the dilemma. concerned in the dilemma.

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Professional Nursing Practice:

Ethics

A

A –– Act by applying the chosen option. ThisAct by applying the chosen option. This step is usually the most difficult because step is usually the most difficult because

it requires actual implementation, whereas it requires actual implementation, whereas the previous steps allow only for dialogue the previous steps allow only for dialogue

and discussion. and discussion.

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Professional Nursing Practice:

Ethics

L

L –– Look back and evaluate the entire process,Look back and evaluate the entire process, including the implementation. No process

including the implementation. No process

is complete without a thorough evaluation.

Ensure that those involved are able to

follow through on the final option. If not,

a second decision may be required and the

process must start again at the initial step.

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Professional Nursing Practice:

Ethics

Ethics committeesEthics committees

Provide structure and guidelines for potential Provide structure and guidelines for potential problems and can provide short term and long problems and can provide short term and long

term assistance. They also serve as open forums term assistance. They also serve as open forums

for discussion and function as true patient for discussion and function as true patient

advocates by placing the patient at the core of advocates by placing the patient at the core of

the committee discussions. the committee discussions.

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Future 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 healthcare

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Future 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 cost nursing 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.