Ethical and Legal Considerations

Code of Ethics

refers to the ideals, duties, and obligations that nurses are expected to uphold as members of the nursing profession.

The International Council of Nurses (ICN) Code of Ethics is a supranational code, meaning?

it forms the basis of national codes of ethics

Code of Ethics for Nurses with Interpretive Statements

established by the American Nurses Association (ANA). The Code of Ethics includes 10 provisions.

Provisions 1 through 3 of the Code

refer to the fundamental values of the nursing profession and the nurse’s commitment to those that they care for.

• The nurse should provide compassionate care and respect for the client.

• The nurse should recognize that each client is unique, has worth, and deserves to be treated with dignity.

• The nurse should be an advocate for each client’s rights and needs.

• The nurse should promote and protect the health and safety of each client.

Provisions 4 through 6 of the Code

refer to the duty and loyalty that the nurse is expected to show to their clients and themselves.

• The nurse should demonstrate authority, accountability, and responsibility for promoting best practices.

• The nurse should promote health and provide the best care they can for each client.

• The nurse should maintain competence, practice the accepted values of the nursing profession, and promote a healthy and safe practice environment.

• The nurse should adhere to the ethical principles of the nursing profession.

Provisions 7 through 9 of the Code

refer to the duty and loyalty the nurse is expected to show beyond direct client encounters and to the nursing profession as a whole.

• The nurse should promote the profession of nursing through research and inquiry.

• The nurse should participate in the development of standards of practice and policies governing nursing and health care.

• The nurse should collaborate with other members of the interprofessional team to protect the rights of all individuals and decrease health disparities.

• The nurse should promote the integrity of the nursing profession.

10th provision of the Code

emphasizes the importance of enhancing worldwide health and environmental sustainability, advocating for social justice, and focusing on the importance of self-care.

• The nurse has a role in the health of people and the environment on a global scale.

• The nurse is dedicated to tackling health inequalities and advocating for social justice. Racism is recognized as a public health emergency.

• The nurse recognizes that the well-being of the nurse is closely linked to the quality of care they provide to clients.

The ethical principles that have a direct effect on nursing practice include

autonomy, beneficence, nonmaleficence, veracity, fidelity, and justice. 

autonomy

Independence or freedom, ability to make one's own decisions.

beneficence

Doing good and acting in the best interest of a client by providing care that benefits them. 

nonmaleficence

Doing no harm, or the least amount of harm to the client, while trying to achieve the best possible outcome.

veracity

Telling the truth.

fidelity

Keeping promises or commitments.

justice

the nurse’s obligation to provide treatment, care, and resource allocation that is impartial, fair, and equitable to all clients regardless of age, sex, race, or economic status. Even when resources are scarce.

Values

what we believe as individuals to be important, good, and meaningful.

altruism

To do something, or take action, for the sake of benefiting someone else.

Human dignity

each individual, regardless of race, religion, gender, sexual orientation, culture, ethnicity, socioeconomic status, or any of our characteristics or personal preferences, has intrinsic value and should be respected and treated equally.

integrity

The quality of being honest and having strong moral principles. Even when circumstances challenge the nurse’s character.

Autonomy

• the right to self-determination

• refers to the nurse’s responsibility to respect the client’s right to make their own decisions regarding their health care, including the right to refuse care.

Social justice

Change in health policy aimed at analysis and critique of social structures, laws, and customs that harm groups through exclusion. Every person has the right to quality health care.

ethical dilemmas

Situation where a critical choice must be made, but the solution may not be ethically acceptable. 

ethical decision making

Process of evaluating and choosing options in an ethically consistent manner using ethical principles. 

Emergency Medical Treatment and Labor Act (EMTALA)

Ensures that all individuals, regardless of their insurance or financial status, have equal access to emergency medical care.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Health Insurance Portability and Accountability Act, also known as the Privacy Act, is legislation to protect insurance coverage and private information of clients. Its purpose is to protect client privacy and personal health information for security breaches, particularly electronic data. It was established by the federal government with the goal of making health care more efficient.

Established in 1996 to reduce fraud and deter inappropriate use of client health care information.

The ANA has developed six principles for social networking that are directly tied to the Code. These principles provide guidance for using social media in a positive and responsible way. 

1. Nurses should not transmit or post any identifiable client information.

2. Nurses should maintain professional boundaries if communicating with a client through social media.

3. Nurses should refrain from sharing, posting, or distributing any information or images related to a client or obtained through the nurse–client relationship, unless it is necessary for client care or required by law.

4. Nurses must avoid naming clients or sharing information that could reveal a client’s identity. Simply using privacy settings to restrict access to posts is not enough to guarantee privacy.

5. Nurse’s should not speak about clients in a disrespectful manner, even if the client is not directly named.​​​​​​​

6. Nurses are prohibited from taking photos or videos of clients using personal devices, such as cell phones. They should adhere to their employer’s policies when capturing images or videos for treatment or other valid reasons, using devices provided by the employer.

7. Nurses are required to immediately report any discovered violations of confidentiality or privacy.

8. Nurses need to be familiar with and adhere to their employer’s policies concerning the use of company-owned computers, cameras, and other electronic devices, as well as the use of personal devices at work.

9. Nurses should refrain from making negative, threatening, harassing, sexually explicit, racially offensive, vulgar, obscene, or otherwise inappropriate comments about employers or colleagues on social media.

10. Nurses should not publish content or represent the employer publicly unless they have been given permission to do so, and they must comply with all relevant employer policies.

Genetic testing

involves examining a client’s DNA to reveal the individual genetic markings that make that client unique. often searching for answers and may be concerned about hereditary diseases they may not be able to avoid. performed prenatally to detect disorders such as Down syndrome.

Criminal court

Deals with crimes against the public/law. The prosecutor must prove the defendant is guilty beyond a reasonable doubt. The goal is to punish the offender and prevent future crimes.

Civil court

Deals with disputes between people or organizations. The goal is usually to compensate the person who was harmed, often through monetary damages.

tort

Carrying out an act, or failing to carry out an act, which results in injury or harm to a client.

Nurses can help protect themselves from civil and criminal action by taking these steps.

• Research insurance coverage for malpractice and consider purchasing a separate policy.

• Diligently follow the rules, guidelines, policies, and procedures for the facility and state in which they work.

• Review the protection coverage of their employer.

• Be knowledgeable about the Nurse Practice Act of the state in which they are employed

• Put the client first in their practice.

informed consent

Formal permission granted with the knowledge of the possible consequences and alternatives.

• The proposed treatment or procedure

• Who will perform the treatment or procedure

• The purpose of the proposed treatment or procedure

• The expected outcomes of the proposed treatment or procedure

• The benefits of the proposed treatment or procedure

• The possible risks associated with the proposed treatment or procedure

• The alternatives to the particular treatment or procedure

• The benefits and risks associated with alternatives to the proposed treatment or procedure

• The client’s right to refuse a proposed treatment or procedure

Minor consent

• means that, depending on your state and setting, some minors can legally make decisions about their own health care

• especially for things like reproductive health, mental health, and substance use treatment

• without needing a parent or guardian to consent. However, the specific rules vary widely by location and situation.

implied consent

Agreement by the client to the administration of care as demonstrated by the client’s actions rather than by formal verbal or written consent.

advance directives

A written statement of a person's wishes regarding medical treatment.

Examples:

• Living will

• Durable power of attorney for health care

• organ donation form

• Do not intubate (DNI) order

Good Samaritan laws

Provides for protection from claims of negligence for those who provide care without expectation of payment.

whistleblowing

Reporting private information about an organization's wrongdoing or illegal activity.

Mandatory Reporting

Licensed nurses are mandatory reporters. Legislation mandates that certain officials have a legal duty to report information that can prevent maltreatment and provide safety to another individual(s).

Reporting of Maltreatment

If a nurse suspects that a client or individual is experiencing maltreatment, it must be reported to the appropriate agency. Maltreatment may present itself in many forms, including but not limited to the following.

• Physical maltreatment or denying food, shelter, or comfort

• Neglect, denial or delaying of care

• Verbal or emotional maltreatment

• Sexual maltreatment

• Financial exploitation

• Educational maltreatment or neglect

• Lack of protection from harm

In the event that the investigation reveals that maltreatment is not present, a nurse acting in good faith is not held liable for reporting suspicions.

Centers for Disease Control and Prevention (CDC) tracks certain diseases and illnesses that can pose a threat to the general public. Public health departments monitor and report occurrences of these diseases and illnesses. These include, but are not limited to:

• Anthrax

• Botulism

• Chlamydia

• Foodborne disease outbreak

• Hepatitis A–C

• HIV

• Influenza

• Measles

• Rubeola

• Tuberculosis

• Zika virus

In the event the reported disease is a sexually transmitted infection (STI)

it is the responsibility of the agency to locate and contact those who have had sexual contact with the infected individual to assess and coordinate treatment as necessary.

A near-miss incident

an occurrence of an incident in which no harm or injury occurred.

sentinel event

An adverse event that should never occur.

Examples of Sentinel Events: Care management event

• Client fall

• Restraint-related event

• Pressure injury

• Medication error

Examples of Sentinel Events: Criminal event

• Assault

• False imprisonment

Examples of Sentinel Events: Environmental event

• Fire

Examples of Sentinel Events: Protection event

• Client elopement

• Infant abduction

• Self-harm

Examples of Sentinel Events: Suicide

• Suicide while receiving care

• Suicide within 72 hr of discharge

Examples of Sentinel Events: Surgical or invasive procedure events

• Wrong procedure

• Wrong site

• Wrong client

Incident, or occurrence, reporting should occur in the following instances.

• Any event that is outside the routine care of a client, such as a medication error or a missed provider prescription

• Incidents involving workplace violence

• Any near-miss event, such as an expired medication that is identified before it is administered to a client

• Any adverse event that occurs to a client, staff member, or visitor, such as a fall

• Any sentinel event

just culture

Values-supportive model of shared accountability and mindfulness.

Client abandonment

an action in which the provider deserts a client for whom they have established a provider–client relationship without ensuring the continuation of care

Client-to-nurse staffing ratios

best described as the number of clients that the nurse is responsible for providing care to during their shift.

Nurses must follow the five rights of delegation when delegating a task.

• Right task: The task being delegated must be within the job description of the delegatee. Expectations and limitations of the task should also be clearly outlined in the policies and procedures of the facility.

• Right circumstance: The nurse should ensure that the client’s condition is stable. The delegatee must also communicate any changes in the client’s condition.

• Right person: The delegatee must have the ability and knowledge to perform the task.

• Right directions and communications: The nurse must communicate specific instructions to the delegatee. The delegatee should clarify these instructions and ask questions, if needed.

• Right supervision and evaluation: When delegating, the nurse is responsible for monitoring and ensuring that the task is completed appropriately. The nurse must also evaluate the client outcome and ensure that appropriate documentation is completed.

Standards of Practice

Explanatory statements that describe a competent level of care for all nurses, using the critical thinking model known as the nursing process

Standards of Professional Performance

Defines competent behavior of all registered nurses where professional care is provided.

What does HIPAA require nurses to do?

Nurses are legally and ethically required to protect client confidentiality and privacy.

What are the possible consequences of violating client confidentiality?

Nurse: disciplinary action, suspension/termination, fines, criminal penalties, and possible loss of licensure.

→ Institution: civil/criminal penalties and possible loss of Medicare reimbursement.
→ Client: loss of trust, humiliation, shame, stress, and possible loss of employment.

Are confidentiality breaches usually intentional?

No. Most are unintentional and occur because of lack of knowledge or poor judgment/discernment.

How can nurses prevent accidental confidentiality breaches?

Avoid discussing clients in public areas, protect passwords, log out of computers, use verification/code words when communicating information, don't photograph clients with personal phones, and don't post about clients/work on social media.

What should a nurse do if they see a coworker violating confidentiality?

Intervene and follow the chain of command. For a minor issue, remind the coworker (e.g., log out or shred documents). Repeated/serious violations should be reported to the nurse manager, supervisor, or privacy officer.

What can happen if a nurse's confidentiality violation is reported to the State Board of Nursing?

The nurse may receive a reprimand, monetary penalty, or loss of nursing licensure.

What is the most important principle to remember about confidentiality?

Protect client information at all times and report breaches appropriately.

Nurse fatigue

the physical and psychological exhaustion that can cause the nurse to be unable to function safely and competently.