Nursing Ethics Notes - Page by Page
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Topic: Ethical foundations of nursing as part of Week 3 course on Ethical and Legal Responsibilities.
Purpose: Understand the ethical foundations of nursing practice and how to navigate complex situations with compassionate, competent care.
Key components to cover: Code of ethics, ethical principles and values, decision-making processes, and legal considerations.
Outcome: By end of this section, you should approach ethical dilemmas with confidence and integrity.
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The Nursing Code of Ethics – Guiding Principles:
Provides guiding principles for nurses to navigate daily ethical dilemmas to ensure patient care aligns with professional values.
The Code is published by the American Nurses Association (ANA).
Establishes standards for:
Maintaining patient confidentiality
Advocating for vulnerable populations
Providing competent, equitable care
Core values:
Centered on respect for human dignity
Right to self-determination
Promotion of health and safety for all patients
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Autonomy (Definition):
The principle of respecting a person’s right to make their own decisions, even if those decisions differ from what others think is best.
Includes informed consent and respecting individuals’ freedom to act according to their values and beliefs.
In Practice:
Example: When a doctor explains risks, benefits, and alternatives of proposed surgery, they honor autonomy, allowing the patient to decide to proceed or decline based on personal values and preferences.
Nurses’ role: Support autonomy by ensuring patients have complete information to make informed choices about their care.
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Beneficence (Definition):
The ethical obligation to do good or promote the well-being of others.
In healthcare, involves acting in the best interest of patients by providing effective treatments and care.
Example in Practice:
A nurse administers medication to a patient in severe pain to improve comfort and well-being, and provides emotional support by listening to concerns.
Key components:
Actively promoting patient welfare
Preventing harm
Removing harmful conditions
Helping persons with disabilities
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Nonmaleficence: "Do No Harm"
Emphasizes avoiding actions that cause suffering.
Includes risk assessment and balancing benefits against potential harms.
Example:
A surgeon double-checks instruments before surgery to avoid mistakes that could harm the patient.
If a treatment option has serious known side effects, a less risky alternative may be chosen.
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Veracity (Truth-Telling):
Veracity is the principle of truth-telling.
Involves providing honest, accurate, and complete information so patients can make informed decisions.
Informed Consent:
Ensuring patients have complete information to make decisions about their care.
Example:
A doctor honestly informs a patient about a terminal illness, including prognosis, treatment options, and likely outcomes.
Nurses’ role:
Support autonomy by ensuring patients understand information and can make informed choices.
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Fidelity (Loyalty and Trust):
Maintaining loyalty, faithfulness, and keeping promises or commitments in the healthcare context.
Involves maintaining patient confidentiality and honoring agreements.
Examples:
A healthcare provider keeps a patient’s medical information confidential, preserving trust.
Following through on promises (e.g., scheduling follow-ups, providing necessary care).
Key components:
Keeping promises
Building trust
Confidentiality (protecting patient information and privacy)
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Justice in Healthcare:
Ensures all patients receive care regardless of background or status.
Involves allocating resources equitably among those in need and working to eliminate healthcare inequalities.
Core ideas:
Fairness and equality in distributing benefits, risks, and resources.
Examples include providing equal access to treatment regardless of socioeconomic status, race, or gender, and supporting systemic changes to promote fairness.
Related concepts: Equal access, Fair distribution, Addressing disparities, Policy advocacy.
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Core Ethical Values in Nursing:
Altruism: Selfless concern for others’ well-being.
Human Dignity: Respecting the intrinsic worth of every person.
Integrity: Maintaining honesty and ethical consistency.
Role of values:
Foundational to nursing practice.
Guide nurses to be not only competent but also compassionate, fair, and respectful.
Summary:
Altruism, Human Dignity, and Integrity form a foundation for ethical nursing conduct.
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Social Justice and Autonomy as Values:
Social Justice (Definition): Fairness and equality in society, ensuring access to resources, rights, and opportunities for all.
Example: A nurse advocates for equal access to healthcare for underserved populations and works to eliminate disparities.
Autonomy as a Value (Definition): Autonomy is not only a principle but a value emphasizing respect for individuals’ right to self-determination in all aspects of care.
Example: A patient is given all necessary information and can make an informed decision without pressure.
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Ethical Dilemmas in Nursing:
Informed Consent: Ensuring patients fully understand procedures while respecting decision-making capacity, especially in emergencies.
Resource Allocation: Making difficult decisions about distributing limited healthcare resources fairly among patients with competing needs.
End-of-Life Decisions: Balancing patient wishes with medical recommendations regarding life-sustaining treatments, palliative care, and advance directives.
Patient Confidentiality vs. Safety: Determining when breaking confidentiality may be necessary to protect the patient or others from harm.
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Ethical Decision-Making Process:
1) Identify the Ethical Issue – Recognize the ethical components of the situation.
2) Gather Information – Collect relevant facts, perspectives, and context.
3) Consider Alternatives – Explore possible courses of action.
4) Evaluate Alternatives – Assess each option against ethical principles.
5) Make and Implement a Decision – Choose and act on the best course of action.
6) Evaluate Outcome – Reflect on results and learn for future situations.Note: The page explicitly lists 5 steps, but the outline shown includes 6 items; use the six-step framing above as a comprehensive guide and be aware of the practice in your course materials.
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Factors Influencing Ethical Decisions:
Laws and institutional policies
Personal beliefs and moral frameworks
Diverse beliefs and practices
Respecting patient autonomy and wishes
Key ideas:
Personal values shape perceptions of situations.
Patient preferences must be respected to honor autonomy.
Cultural and religious considerations affect care interpretation.
Legal and institutional guidelines provide decision-making frameworks.
Categories highlighted:
Personal Values
Cultural Considerations
Patient Preferences
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Emergency Medical Treatment and Labor Act (EMTALA):
Hospitals must provide emergency medical treatment to anyone seeking care, regardless of payment ability or insurance status.
Purpose: Ensure stabilization for emergency medical conditions for all patients.
Patient Transfer:
EMTALA guidelines require stabilization before transfer and ensure receiving facility agrees to accept and provide appropriate care.
Non-Discrimination:
Law prohibits discrimination based on insurance status, nationality, or other factors; all patients must receive the same standard of screening and stabilizing care.
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Health Insurance Portability and Accountability Act (HIPAA, 1996):
Establishes national standards for protecting sensitive patient health information.
Key components:
Confidentiality requirements for all patient data
Security measures for protecting health information
Patient rights to access records and control information
Mandatory staff training
Regulations for electronic health records (EHRs)
Procedures for reporting violations
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Civil Laws in Nursing Practice – Categories of Torts:
Civil laws protect rights in non-criminal matters (disputes, contracts, negligence) and focus on compensation.
Two categories:
Intentional Torts
Unintentional Torts
Examples:
Intentional Torts: Defamation, battery, invasion of privacy, assault
Unintentional Torts: Negligence and malpractice
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Understanding Intentional Torts (Types, Definitions, and Nursing Examples):
Defamation: False statements harming reputation (slander or libel)
Invasion of Privacy: Intruding into personal life or information without consent
Assault: Creating fear of imminent harmful contact; Battery: Actual harmful or offensive contact without consent
Nursing Examples:
Defamation: A nurse falsely claims another nurse is incompetent, harming reputation
Battery: Administering an injection to a patient who refused it
Invasion of Privacy: Accessing patient records without authorization or clinical need
Threatening gestures toward a patient
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Negligence and Malpractice:
Negligence: Failure to exercise the care that a reasonable person or professional would in similar circumstances.
Example: A nurse forgets to check vital signs post-surgery, leading to an unrecognized deteriorating condition.
Key Elements: Duty of care, breach of duty, causation, and resulting harm.
Malpractice: A specific type of negligence that involves failure to meet professional standards of care.
Example: A nurse administers the wrong dosage due to not following protocols.
Distinction: Negligence is a general failure; malpractice specifically involves professional standards.
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Preventing Legal Issues in Nursing through:
Thorough documentation: Maintain detailed, accurate, and timely records of patient care, interventions, and observations.
Following protocols: Adhere to hospital policies, procedures, and standards of care; stay updated on changes.
Continuing education: Stay current with best practices and advances; maintain competency and pursue certifications.
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Integrating Ethics and Legal Practice:
Ethical Principles
Professional Values
Legal Knowledge
Decision-Making Skills
Communication
Documentation
Message:
Ethical and legal considerations are intertwined and guide you to provide care that is morally sound and legally compliant.
Applying these concepts helps in patient advocacy and upholding nursing standards throughout your career.
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Understanding Informed Consent – Purpose and Definition:
Purpose: Respects patient autonomy, establishes trust, and creates a legal record of consent.
Definition: A fundamental ethical and legal principle ensuring patients understand and voluntarily agree to medical treatment or procedures.
Key Components:
Providing patients with adequate information about diagnosis, treatment options, risks, benefits, and alternatives to enable informed decisions.
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Types of Informed Consent:
General Informed Consent: Routine procedures or treatments common in healthcare; typically obtained at the start of the patient-provider relationship.
Example: Consent to be examined, receive diagnostic tests, and undergo routine treatments like taking medications.
Minor Consent: For individuals under 18; usually requires parent/guardian approval with exceptions (emancipated minors, mature minor doctrine).
Example: 17-year-old seeking treatment for a sports injury typically requires parental consent.
Implied Consent: Inferred from patient’s actions or behavior rather than explicit statement; applies to non-invasive or routine care.
Example: A patient extends their arm for a blood pressure check, implying consent for that procedure.
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Minor Consent – Special Considerations (Under 18):
Mature Minor Doctrine: Some jurisdictions permit minors to consent independently for certain services.
Emancipated Minors: Minors who have legal independence from parents can provide their own consent.
Generally, parents or guardians provide consent for medical treatment unless specific legal allowances apply.
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Elements of Valid Informed Consent:
Disclosure: Healthcare providers must share all relevant information about the procedure, including risks, benefits, and alternatives.
Competence: The patient must have the capacity to understand the information and make a decision.
Voluntariness: The decision must be made freely, without coercion.
Understanding: The patient must comprehend the information and explicitly accept the proposed treatment.
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The Nurse’s Role in Informed Consent and Patient Advocacy:
Advocacy: Nurses advocate for patients who may need additional information or support during the consent process.
Documentation and Witnessing: Nurses may serve as witnesses to consent and ensure proper documentation in the medical record.
Providing Information and Clarifications: Help explain procedures in understandable terms and answer questions to augment the provider’s explanation.
Confirming Understanding and Voluntariness: Assess whether patients truly understand information and are making free decisions.
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Good Samaritan Laws – Protection for Good Faith Assistance:
Legal protection for those who provide reasonable assistance in emergencies.
Health care professionals coverage: Special provisions for off-duty providers.
Reasonable Standard of Care: Protection applies when care meets reasonable standards; does not cover gross negligence or willful misconduct.
Variation by state: Laws differ by state and encourage helping in emergencies without fear of liability.
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Whistleblowing in Healthcare:
Definition: Reporting illegal, unethical, or dangerous practices within a healthcare organization to internal or external authorities.
Proper Steps:
Document issues
Report internally first
Consult legal counsel
Follow applicable laws when considering whistleblowing
Ethical Responsibility: Nurses have a duty to report practices that endanger patient safety or violate professional standards.
Whistleblower Protection: Federal laws protect employees who report violations from retaliation (Whistleblower Protection Act).
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Mandatory Reporting Requirements:
Child Abuse: Nurses must report suspected physical, sexual, or emotional abuse, neglect, or exploitation of minors to child protective services or law enforcement.
Elder Abuse: Report suspected abuse, neglect, or financial exploitation of elderly individuals to adult protective services.
Abuse of Vulnerable Adults: Similar reporting for disabled or vulnerable adults.
Domestic Violence: Many states require healthcare providers to report suspected domestic violence; laws vary by jurisdiction.
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Reportable Diseases to CDC – Infectious Diseases and Health Care-Associated Infections:
Notable infectious diseases include Zika virus, West Nile virus, Lyme disease, malaria.
Foodborne and Waterborne: Salmonella, E. coli, norovirus, cholera.
Vaccine-Preventable: Measles, mumps, pertussis, diphtheria; TB, meningitis, hepatitis, HIV/AIDS (reporting varies by state).
Healthcare-associated infections: MRSA, C. difficile, surgical site infections.
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Incident Reports – Definition and Purpose:
Written documentation of events that deviate from standard procedures.
Analysis: Helps identify patterns and system issues.
Risk Management/Quality Assurance: Supports patient safety and quality improvement.
Purpose: Facilitate learning and prevent recurrence by investigating what happened and why.
Key details typically recorded: facts, actions taken, people involved.
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Types of Incidents Requiring Reporting:
Patient falls
Medication errors
Patient injuries
Equipment failures
Violence or aggression
Failure to follow protocols
Near misses
Wrong-site surgeries
Infection control breaches
Emphasis: Prompt and accurate reporting is essential for safety, quality improvement, and risk management.
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Incident Report Submission Process:
First submission point: Nurse’s immediate supervisor or unit manager.
Patient Safety Committee: Reviews incidents to identify patterns and recommend system improvements.
Risk Management/Quality Assurance: For tracking and analyzing the incident.
Administration and Legal Department: Senior leadership and legal counsel review serious incidents for potential liability and organizational response.
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Proper Documentation in Incident Reports – Avoid Subjective Elements:
Do not include personal opinions or subjective statements.
Do not admit fault or responsibility; avoid speculation about causes.
Do not include unrelated patient medical details or blaming language.
Do include objective information: date and time, precise location, factual description, people involved, immediate actions, witnesses, equipment involved, follow-up actions.
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Client-to-Nurse Staffing Ratios (California):
Medical-Surgical: 1 nurse to 5 patients (1:5)
Emergency/Pediatrics: 1:4 (1:4)
Critical Care (ICU/CCU) and PACU: 1:2 (1:2)
Labor & Delivery: 1:2 (1:2)
Context:
These are California’s state-m mandated minimum nurse staffing ratios.
Ratios vary by unit type and patient acuity.
Importance: Staffing ratios impact patient safety, quality of care, and nurse well-being.
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The Five Rights of Delegation (Right Task):
Delegating tasks that are appropriate and within the scope of the recipient’s practice.
Right Circumstance:
Ensure setting, resources, and patient stability are appropriate for delegation; patient condition should be stable and predictable.
Right Person:
Choose someone with appropriate skills, knowledge, and legal authority; the delegate must be competent for the task.
Right Direction / Communication:
Provide clear, concise instructions about the task, expected outcomes, and reporting requirements (what, when, where, how, why).
Right Supervision / Evaluation:
Monitor performance, provide feedback, and evaluate outcomes; level of supervision should match task complexity and experience.
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Legal Issues in Nursing Practice – Key Concepts:
Client Abandonment: Terminating care without reasonable notice or adequate replacement, risking patient harm and legal liability.
Lack of Confidentiality: Unauthorized disclosure of patient information, violating HIPAA and privacy laws; penalties and trust damage.
Falsification of Records: Recording inaccurate information in health records; constitutes fraud and endangers patient safety.
Nurse Fatigue: Working while excessively tired, increasing error risk and potential negligence if harm occurs.
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Substance Use Disorder Among Nurses – Risk Factors and Responses:
Risk Factors: High-stress environments, access to medications, shift work disrupting sleep, workplace culture.
Professional Support: Many states offer confidential alternatives-to-discipline programs to treat nurses while protecting licenses.
Warning Signs: Frequent absences, mood swings, decreased work performance, medication discrepancies, volunteering to administer narcotics, isolation.
Legal Implications: Substance use while practicing can lead to license suspension or revocation, criminal charges, and civil liability if patient harm occurs.
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Advanced Directives: Living Will – Living Will Definition and Role:
A living will is a written document outlining preferences about medical treatment when a person cannot communicate due to illness or injury.
Key Components: Directions about life-sustaining treatments (resuscitation, mechanical ventilation, feeding tubes, end-of-life care).
When Used: In terminal illness or persistent vegetative state.
Nurse’s Role: Help patients understand living will options, file documentation, advocate for adherence to patient wishes, support families.
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Advanced Directives: Health Care Proxy, DNR, and Other Directives:
Health Care Proxy / Durable Power of Attorney for Healthcare: Appoints a proxy to make healthcare decisions if the patient is unable.
Do Not Resuscitate (DNR): Indicates a patient’s wish not to receive CPR or life-saving measures if heart stops or they stop breathing.
Context: These directives are critical for end-of-life care and aligning care with patient autonomy.
Nurse’s Role: Understand and advocate for patient wishes, ensure directives are reflected in care plans, and communicate with families and other providers when appropriate.