Ethical and Legal Considerations in Nursing Practice

Learning Objectives

  • Explore the Code of Ethics related to the nursing profession.
  • Discuss values and their role in ethical decision-making.
  • Discuss the relationship of ethical and legal practice to the role of nurses.
  • Explore actions related to a breach of nursing practice and potential consequences.

Code of Ethics and Ethical Principles

  • Code of Ethics for Nurses:

    • Establishes the foundational moral standards and ethical duties of the nursing profession.
    • Composed of specific provisions outlining professional expectations, client advocacy, and ethical responsibility.

  • Core Ethical Principles:

    • Autonomy ("Their choice"): Respecting and upholding the client's right to self-determination and independent decision-making regarding their healthcare.
    • Beneficence ("Do good"): Taking active, positive steps to promote the well-being of others and acting in the best interest of the patient.
    • Nonmaleficence ("Do no harm"): The obligation to avoid inflicting harm, injury, or unnecessary suffering on patients.
    • Veracity ("Tell the truth"): Truthfulness, honesty, and transparency in all clinical interactions and communication with clients.
    • Fidelity ("Keep your word"): Loyalty, keeping commitments, fulfilling promises, and maintaining trust with patients and healthcare team members.
    • Justice ("Fair for all"): Ensuring fairness, equity, and appropriate, unbiased distribution of healthcare resources and treatment.

Ethical principles directional sign

Core Nursing Values

  • Essential professional values guiding ethical decision-making and patient interactions:
    • Altruism: Unselfish concern for the welfare, health, and well-being of others.
    • Human Dignity: Universal respect for the inherent worth, uniqueness, and value of every individual human being.
    • Integrity: Acting in accordance with professional standards of practice, honesty, and an established code of ethics.
    • Autonomy: Honoring and supporting the rights of individuals to make decisions about their own health care.
    • Social Justice: Upholding moral, legal, and humanistic principles by ensuring equal access, fair care, and non-discriminatory treatment for all populations.

Core values in nursing

Steps in Ethical Decision Making

  • Step 1: Define the Issue and Assess Risks: Clarify the precise ethical problem and evaluate the potential risks involved.
  • Step 2: Identify Stakeholders: Determine all individuals, families, or groups affected by the decision.
  • Step 3: Gather Information: Collect all relevant clinical facts, client preferences, legal boundaries, and background context.
  • Step 4: Reflect on Personal Biases: Introspect to identify any personal beliefs, values, or personal biases that could influence objective clinical judgment.
  • Step 5: Identify Core Principles and Standards: Determine which ethical principles, professional codes, and regulatory standards apply to the case.
  • Step 6: Consult Resources: Seek guidance from ethics committees, policy manuals, clinical guidelines, or interprofessional specialists.
  • Step 7: Develop Action Options: Brainstorm potential courses of action to address the problem.
  • Step 8: Critically Evaluate Each Option: Analyze the benefits, harms, pros, and cons of each proposed option.
  • Step 9: Select the Best Action: Choose the most ethically sound action option.
  • Step 10: Implement the Action: Execute the selected clinical plan effectively.
  • Step 11: Evaluate the Outcomes: Review the results of the decision to verify if the ethical dilemma was resolved successfully.

Ethical and Legal Practice Frameworks

  • Emergency Medical Treatment and Labor Act (EMTALA):

    • Federal statute requiring that Emergency Departments (ED) cannot turn away clients for being under-insured or uninsured, or because of their inability to pay.
    • Mandates medical screening examinations and stabilizing treatment for emergency conditions regardless of financial status.

  • Health Insurance Portability and Accountability Act (HIPAA) of 1996:

    • Legally protects client health information privacy and security standards across healthcare systems.
    • Restricts unauthorized disclosure of Protected Health Information (PHI).

  • Social Media and Confidentiality:

    • Requires strict adherence to patient privacy rules across all digital and social media networks.
    • Prohibits posting any identifiable patient details, photos, or clinical scenarios.

  • Genetic Testing:

    • Involves ethical considerations surrounding genetic privacy, informed consent, and protection against genetic discrimination in insurance and employment.

Criminal Law, Civil Law, and Consent

  • Criminal and Civil Law:

    • Establishes statutory boundaries, legal liabilities, and consequences for nursing practice breaches, negligence, or unlawful conduct.

  • Informed Consent ("I understand and I agree."):

    • Process that provides the client with comprehensive details regarding risks, benefits, and alternatives of a proposed treatment or procedure.
    • Minor Consent: Legal provisions specifying circumstances under which minors can consent or require parental/guardian consent for medical care.

  • Implied Consent ("My actions show that I agree."):

    • Assumed consent inferred through client conduct, non-verbal actions, or emergency situations where explicit consent cannot be immediately obtained.

Advance Directives and Legal Safeguards

  • Advance Directives (AD): Legal documents specifying a client's healthcare preferences prior to losing decision-making capacity.

    • Living Will: Written document detailing explicit instructions regarding life-sustaining measures and desired treatments during terminal or end-of-life conditions.
    • Durable Power of Attorney (POA): Legal designation of a surrogate decision-maker (healthcare proxy) authorized to make medical decisions if the client becomes incapacitated.

  • Good Samaritan Laws:

    • Provide legal immunity and protection against civil liability to healthcare professionals who render emergency care in good faith outside institutional settings.

  • Whistleblowing:

    • Statutory protections for healthcare workers who report unsafe, illegal, fraudulent, or unethical organizational practices.

  • Mandatory Reporting:

    • Reporting of Maltreatment: Statutory duty to report suspected abuse, neglect, or exploitation of vulnerable individuals (e.g., children, elderly, disabled).
    • Reporting of Incidence of Disease: Required notification of communicable disease outbreaks to public health departments.
    • Reporting Incidents: Institutional obligation to document and report adverse events, safety breaches, and unusual occurrences.

Breach of Nursing Practice

  • Standards of Care: The standard level of clinical skill, knowledge, and care expected of a reasonably prudent nurse under similar circumstances.
  • Standards of Practice and The Code of Ethics: Violations of established standards, duties, or ethical guidelines constitute a practice breach.
  • Lack of Confidentiality: Unauthorized disclosure or improper handling of private client health records.
  • Falsification of Health Records: Intentionally altering, misrepresenting, or forging patient medical records or documentation.

Standards of Professional Performance

  • Standards of Professional Performance Elements:
    • Culturally congruent practice
    • Ethics
    • Leadership
    • Communication
    • Environmental health
    • Evidence-based practice
    • Education
    • Collaboration
    • Resource utilization
    • Professional practice evaluation
    • Quality of practice

Sentinel Events

  • Definition: Unanticipated occurrences involving death, serious physical or psychological injury, or significant risk thereof.

Examples of Sentinel Events

  • Categories and Examples of Sentinel Events:
    • Anesthesia-related event: Anesthesia medication error, airway management event.
    • Care management event: Client fall, restraint-related event, pressure injury.
    • Criminal event: Assault, false imprisonment.
    • Environmental event: Fire.
    • Product or device event: Failure of intravenous infusion device.
    • Protection event: Client elopement, infant abduction, self-harm.
    • Suicide: Suicide while receiving care, suicide within 72 hr72\,\text{hr} of discharge.
    • Surgical or invasive procedure events: Wrong procedure, wrong site, wrong client.

Nurse Fatigue and Substance Use Disorder

Causes, manifestations, and effects of nurse fatigue

  • Nurse Fatigue:

    • Causes of Nurse Fatigue:
    • Long and varying shifts
    • Increased client load
    • Nursing shortages
    • Manifestations of Nurse Fatigue:
    • Physical exhaustion
    • Psychological exhaustion
    • Negative Effects on the Nurse:
    • Increased risk of chronic illnesses
    • Increased risk of mental health disorders
    • Decreased clinical judgment
    • Decreased communication with the interprofessional team
    • Negative Effects on the Client:
    • Increased risk of medication errors
    • Increased risk of receiving unsafe care
    • Increased client mortality rate

  • Substance Use Disorder Among Nurses:

    • Impairment caused by chemical dependency impacting clinical practice, safety, and performance; requires immediate reporting, non-punitive intervention options, and structured rehabilitation.

Patient Safety Governance

Patient safety and interprofessional collaboration triangle

  • Interprofessional Safety Triangle:
    • Central Focus: Patient safety
    • Administration: Interacts with nurse leaders through education and training, and with staff via open communication.
    • Nurse Leaders: Connect with staff through review and feedback, and with administration through education and training.
    • Staff: Collaborates with administration via open communication and nurse leaders via review and feedback.

Legal Implications Related to Workforce Issues

  • Client Abandonment: Unlawfully severing the nurse-client relationship without giving reasonable notice or making proper arrangements for continuation of care.
  • Client-to-Nurse Staffing Ratios: Regulated workload limits establishing the maximum number of patients assigned to a nurse to ensure clinical safety.
  • Delegation:
    • Reassigning responsibility for performing a specific nursing task to a qualified individual while retaining ultimate accountability for the outcome.
    • Five Rights of Delegation:
    1. Right Task: Task is appropriate to delegate for a specific client.
    2. Right Circumstance: Task is delegated in an appropriate patient setting with adequate resources.
    3. Right Person: Right person delegating the right task to the right delegatee for the right client.
    4. Right Direction and Communication: Nurse provides clear, concise, and unambiguous task directions, limitations, and expectations.
    5. Right Supervision and Evaluation: Nurse monitors, evaluates performance, intervenes as necessary, and provides feedback.

Delegation to Unlicensed Assistive Personnel (UAP)

  • Rule of Thumb — Remember the 3 F's:

    • Feeding
    • Fetching
    • Fundamentals of daily care

  • Delegable Tasks for Unlicensed Assistive Personnel (UAP):

    • Activities of Daily Living (ADLs): bathing, dressing, grooming
    • Feeding a patient
    • Assisting to the bathroom
    • Oral hygiene
    • Obtaining vital signs on stable patients (must report abnormal results to nurse)
    • Measuring intake and output
    • Weighing patients daily
    • Stocking supplies
    • Repositioning patients
    • Ambulating patients
    • Answering call lights