Legal and Ethical Aspects of Nursing Flashcards

Legal Aspects of Nursing

• Modern Healthcare Context: The current health care system is dynamic, complex, and has undergone significant changes. Practice is guided by laws, rules, regulations, and ethical principles. Key influences include rising costs, growing consumer awareness, rapid technological advances, and a shift toward managed care, community health, and home health care.
• Nurse-Patient Legal Relationship: This relationship is influenced by existing laws and regulations. Acting outside the scope of practice or failing to meet standards of care can result in patient injury, legal liability, and the possible loss or sanction of a nursing license.
• The Legal System: Defined as a complex set of rules and regulations developed in response to societal needs. Laws prescribe proper behavior, sanction acceptable behavior, and prohibit unacceptable behavior.
• Categories of Law:     * Criminal Law:         * Involves conduct offensive or detrimental to society as a whole.         * Relates to public offenses such as robbery, murder, and assault.         * Purpose: To punish the crime and deter/prevent further crimes.         * Outcome: Finding of guilt or innocence; penalties include fines, incarceration, or both.     * Civil Law:         * Involves conduct that violates a person's rights and is detrimental to the individual.         * Purpose: To make the aggrieved person "whole" again (restoration).         * Outcome: Determination of accountability or innocence; penalties involve monetary settlements.
• Law Development:     * Statutory Law: Developed by federal, state, and local governments.     * Common Law (Case Law): Evolves from specific legal questions before the court and usually follows precedent (previous rulings on an issue).

Negligence and Malpractice

• Negligence: Defined as the absence of due care or failure to act as a prudent individual would. It is often attributed to carelessness. Examples include medication errors, patient falls, inappropriate use of restraints, and equipment injuries. Professional-level judgment is not required to establish negligence.
• Malpractice (Professional Negligence): Requires four key elements to establish liability:     1. Duty: The established relationship between the patient and the nurse.     2. Breach of Duty: Failure to perform the duty in a reasonable, prudent manner.     3. Harm: Injury to the person or property (not restricted to physical injury).     4. Proximate Cause: The harm occurred as a direct result of the breach of duty.
• Case Study: Busta v. Columbus Hospital Corporation (1996): A patient died after falling from a third-floor window using an improvised rope. The nurse failed to report tachycardia, hypertension, and atypical behavior (isolation, refusal of care/medication) to the physician. The jury assigned $70\%$ liability to the hospital and $30\%$ to the patient due to contributory negligence. Damages were awarded to the estate ($3500$) and heirs ($560,000$).
• Levels of Responsibility:     * Personal: Individual is responsible for their own acts.     * Manager/Supervisor: Implicated if there was inappropriate supervision or delegation.     * Employer: Responsible for deficits in education, inappropriate credentials, or failure to provide needed supplies/equipment.

The Legal Process and Civil Litigation

• Litigation Steps:     1. The Complaint: Written by the plaintiff (complaining party), naming the defendant (alleged liable party), stating facts, defining legal issues, and outlining damages (sought compensation).     2. The Summons: A court order notifying the defendant of the legal action.     3. Discovery: Process allowing both sides to review documents and interview witnesses. Tools include:         * Deposition: Out-of-court questioning under oath; statements are recorded and become evidence.         * Interrogatory: Written questions requiring legally mandated answers.         * Request for Production of Documents and Things: Formal request for medical records, policies, personnel files, etc.         * Admission of Facts: Requesting a party to admit or deny statements to streamline the case.     4. Verdict: The final decision rendered by the court.     5. Appeal: Request for a higher court to review the decision due to perceived errors in the process or court conduct.

Key Legal Terminology

• Abandonment: Wrongful termination of providing patient care.
• Assault: Intentional threat to cause bodily harm; does not require actual contact.
• Battery (Civil/Technical): Unlawful touching of another person without informed consent; intent to harm is not necessary.
• Competency: Legal presumption that an adult can make decisions for themselves unless declared otherwise.
• Defamation: Malicious statements (spoken or written) that injure reputation.     * Libel: Written defamation.     * Slander: Spoken defamation.
• Tort: Civil law involving wrongs against a person or property (includes negligence, assault, battery, fraud, false imprisonment).

Standards of Care and Regulation

• Standards of Care: Define acts whose performance is required, permitted, or prohibited. They derive from federal/state laws and professional organizations like the American Nurses Association (ANA).
• Nurse Practice Acts: State, provincial, or territorial laws that formally define and limit the scope of nursing practice.
• Evidence of Standards: Used by courts to determine if care was met, including Joint Commission criteria, agency policy manuals, ANA Code for Nurses ($2001$), ANA Standards of Practice ($1995$), and expert nurse witnesses.
• Common Breaches: Failure to properly assess, use proper judgment, maintain airway, honor advance directives, notify physicians of status changes, or document in a timely fashion (pre-charting is a violation).

Patient Rights and Responsibilities

• The Patient Care Partnership ($2003$): Modified from the $1972$ Patient's Bill of Rights; outlines expectations regarding rights and responsibilities.
• Patient Self-Determination Act ($1990$): Requires institutions receiving federal funding to maintain written policies on advance directives and the right to refuse treatment.
• Health Insurance Portability and Accountability Act (HIPAA) ($1996$): Took full effect April $14, 2003$. It sets rules and limits on administrative, technical, and physical safeguards for health information.
• Protected Health Information (PHI): Includes $18$ identifiers, such as names, geographic data smaller than a state (zip codes), dates (admission, discharge, ages over $89$), social security numbers, URLs, and biometric identifiers.
• Informed Consent: Full disclosure of facts for an intelligent decision regarding invasive procedures. Patient must be at least $18$ years old or qualify as a minor via marriage, court-approved emancipation, living apart for $60$ days, or serving in the armed forces.

Nursing Professionalism and Conduct

• Accountability: Being responsible for one's own actions; the basis for legal duty.
• Advocate: One who defends or pleads a cause on behalf of another; nurses have a legal/ethical obligation to safeguard patient interests.
• Seven Preventable Omissions in Nursing:     1. Failure to collaborate.     2. Failure to clarify interdisciplinary orders.     3. Failure to ask for/offer assistance.     4. Failure to utilize evidence-based performance.     5. Failure to communicate information to patients/families.     6. Failure to limit overtime.     7. Inadequate staffing/credentialing.
• Social Media: Pitfalls include blurring boundaries and violating privacy. Examples: A nurse fired for photographing an empty trauma room (#Man vs 6 Train) or posting on Facebook while providing care. ANA and NCSBN released a joint position paper on social media in $2011$.

Mandatory Reporting and Safety

• Abuse Reporting: Nurses are mandated reporters for child abuse (Child Abuse Prevention Treatment Act, $1973$), spousal abuse, and elder abuse.
• Elder Abuse Risks: Declining physical/mental health, isolation, loss of independence, and impaired communication.
• Workplace Violence: Includes verbal abuse, sexual harassment, and physical assault. Institutions must implement security and monitoring.
• Good Samaritan Laws: Provide immunity from liability in emergencies outside medical facilities, except in cases of gross negligence.
• Documentation: The medical record is the best defense; legal presumption: "Care was not given if it was not charted."

Insurance and Licensure

• Professional Liability Insurance:     * Claims-made policy: Protects only while the policy is in force.     * Occurrence-basis policy: Protects against events that occurred during the policy period, even if the claim is made later.
• Disciplinary Defense Insurance: Provides legal representation for license protection and wage loss reimbursement.
• Sanctions Against License: Dismissed charge, letter of reprimand, probation, mandated diversion programs, suspension, or revocation.

Ethical Principles in Nursing

• Ethics: Values influencing behavior and beliefs about right and wrong.
• Process of Value Clarification: Self-evaluation involving selecting a belief, examining it, and incorporating it into behavior.
• Core Ethical Principles:     * Respect for People: Viewing all life as sacred; everyone has inherent worth.     * Autonomy: Freedom of personal choice and independence.     * Beneficence: Doing good; acting for someone's well-being.     * Nonmaleficence: To do no harm.     * Justice: Concept of fairness; all patients have the same right to nursing interventions.

Advance Directives

• Living Will: Directs treatment during terminal illness; requires two witnesses (neither can be a relative or physician).
• Durable Power of Attorney for Health Care: Designates an agent/proxy to make decisions if the patient is incapacitated.
• Cruzan v. Director, Missouri Dept. of Health ($1990$): Upheld the state's right to require "clear and convincing evidence" of an incompetent patient's wishes to withdraw life support (including nutrition and hydration).

Ethical Issues and Reporting

• Practitioner-Assisted Suicide (PAS): Active euthanasia; ANA opposes PAS as inconsistent with nursing philosophy (nonmaleficence).
• Ethical Dilemmas: Situations without clear right or wrong answers; require assessment and ethics committee involvement.
• Reporting Unethical Behavior: Duty to report behavior that puts patients at risk, involves substance use, or violates statutes. Use the proper chain of command and objective documentation.
• Refusal to Treat: Nurses may request a different assignment if a procedure (e.g., abortion) conflicts with personal morals, but cannot abandon the patient or refuse care based on diagnosis (e.g., HIV) or lifestyle.

Questions & Discussion (NCLEX Review)

• Q1: The LPN/LVN reviews the Nurse Practice Act (NPA) to define the scope of nursing practice.
• Q2: A primary duty of patient advocacy is to safeguard the well-being of every patient.
• Q3: If a nurse allows a patient to walk alone against orders and they fall, the nurse is guilty of negligence.
• Q4: The right to refuse medication is established by the Patient Self-Determination Act.
• Q5: A top defense against a lawsuit is to promote a positive nurse-patient relationship.
• Q6: Treating patients as individuals reflects respect for people.
• Q7: The purpose of a code of ethics is to give the nurse guidelines for ethical decision making.
• Q8: Responding to a family's questions about surgery involves confidentiality and invasion of privacy.
• Q9: Before working with terminal children, a nurse should perform value clarification.
• Q10: Advance directives allow a patient to exercise the right of autonomy.
• Q11: Providing interventions regardless of race/religion is justice.
• Q12: Giving an injection to a patient who refused it is civil battery.
• Q13: Taking a photo of a patient even with a coworker is a violation of the right to privacy.
• Q14: Losing a notebook with patient information is a violation of HIPAA.
• Q15: If a nurse is unfamiliar with a procedure, they should review the agency procedure and seek assistance from an experienced nurse.
• Q16: Unit managers have liability if measures are not followed to ensure staff competency and equipment use.
• Q17: Social media benefits include professional networking, educational opportunities, and access to mentoring.
• Q18: Regarding social media, nurses must know that any patient info aiding identification is a violation; names are not the only identifiers.