Potter & Perry Chapter 10 - Legal Implications in Nursing Practice - PPN 101
Objectives of the Chapter
Mastery of content in this chapter will enable you to:
Define key legal and ethical terms.
Differentiate between the governance roles of the four "pillars" of the nursing profession.
Discuss the Regulated Health Professions Act (RHPA) and the Nursing Act, 1991, including concepts of scope of practice, controlled acts, and health regulatory colleges.
Analyze the roles of the nursing profession and other health care professions within the RHPA framework.
Analyze patient safety, accountability, and advocacy in relation to being a regulated health professional.
Discuss the four ethical principles of autonomy, beneficence, nonmaleficence, and justice.
Explore the relationship between ethics and professional practice, focusing on responsibility, accountability, advocacy, and moral agency.
Discuss the importance of informed consent in patient care settings and identify the nurses’ role.
Discuss the principles of ethical decision making and the concepts of "moral distress" and "moral resilience" in nursing.
Identify ethical dilemmas nurses may encounter in clinical practice and discuss possible strategies to resolve them.
Key Terms
Advance Directive: A legal document allowing individuals to express their wishes regarding medical treatment in case they are unable to communicate.
Assault: An act that causes another to fear imminent harmful or offensive contact.
Autonomy: The patient’s right to make their own decisions about their health care.
Beneficence: The ethical principle of doing good and acting in the best interest of the patient.
Controlled Act: Specific health care activities that pose a risk of harm if performed by an unqualified person, regulated by legislation such as the RHPA.
Fiduciary Duty: A legal obligation of one party to act in the best interest of another.
Informed Consent: The process of obtaining a patient’s consent, ensuring they understand the risks, benefits, and alternatives to the proposed treatment.
Justice: The ethical principle of fairness and equitable distribution of health care resources.
Moral Agency: The capacity of an individual to make ethical decisions and be held responsible for them.
Moral Distress: Occurs when a moral agent knows the ethically appropriate action but is unable to act upon it due to internal or external barriers.
Moral Resilience: The capacity to sustain or restore integrity in response to moral adversity.
Negligence: The failure to exercise appropriate care, leading to harm.
Nonmaleficence: The ethical principle of avoiding harm to patients.
Nursing Practice Acts: Laws regulating the nursing profession in each province or territory, often under broader legislation like the RHPA.
Professional Liability Protection: Insurance protecting nurses against claims of negligence.
Regulated Health Professions Act (RHPA): Provincial legislation, such as in Ontario, that governs all regulated health professions, including nursing, defining their scope of practice and controlled acts.
Scope of Practice: The procedures, actions, and processes that a health care practitioner is permitted to undertake in keeping with the terms of their professional license.
Standards of Care: Established criteria to guide nursing practice, ensuring safe and competent care.
Tort: A civil wrong done by one party to another.
Understanding Legal Boundaries in Nursing
Importance: Safe nursing practice requires knowledge of legal boundaries to avoid liability and protect patient rights. Understanding laws is essential for effective patient advocacy.
Dynamism of Laws: Continuous evolution of laws reflects societal changes and the expansion of nursing roles; nurses must remain informed about provincial laws affecting their practice.
The Structure of Nursing as a Profession and Regulatory Framework
Collaboration is key in nursing, with over 400,000 regulated nurses in Canada. The profession includes:
Registered Nurses (RNs)
Registered Practical Nurses (RPNs)
Registered Psychiatric Nurses
Nurse Practitioners
Regulatory Framework: Each province and territory has its legislation governing nursing practice including the Nursing Practice Acts. In Ontario, the Regulated Health Professions Act (RHPA), and under it, the Nursing Act, 1991, establish the regulatory body for nurses (e.g., the College of Nurses of Ontario), their scope of practice, and controlled acts. These acts set entry-level competencies and expectations for ethical conduct.
Roles of the Nursing Profession and Other Health Care Professions within the RHPA
The RHPA provides a framework for all regulated health professions to ensure qualified, competent, and ethical practice.
Nursing Roles: Defined by the Nursing Act, 1991, nurses' roles involve assessment, diagnosis, planning, implementation, and evaluation of care within their authorized scope of practice and controlled acts.
Other Health Care Professions: The RHPA also regulates other professions (e.g., physicians, physiotherapists, pharmacists), defining their roles, scopes of practice, and controlled acts, ensuring interprofessional collaboration while maintaining distinct professional accountabilities.
Four Pillars of Nursing
Regulator: Protects public by ensuring adherence to laws, setting standards, and investigating complaints.
Professional Association: Advances the profession and health through policy, advocacy, and professional development.
Educational Institutions: Ensures nursing programs meet standards and prepares future nurses for practice.
Union: Advocates for nurses’ rights, healthy work environments, and fair work conditions.
Patient Safety, Accountability, and Advocacy
Fiduciary Duty: Nurses owe a duty of care to their patients, providing knowledge-based and competent care as a part of their professional integrity. This forms the basis of accountability.
Growing Public Awareness: Increased public knowledge regarding rights has led to a higher incidence of legal claims, demanding higher standards of care and increasing professional accountability.
Responsibility of Regulatory Bodies: Ensure public safety by setting and enforcing standards of practice and investigating complaints.
Standards of Care: These established criteria guide nursing practice, ensuring safe and effective care. Deviations can lead to legal consequences and are a key measure of accountability.
Professional Liability Protection: Provides insurance against claims of negligence, supporting nurses in maintaining accountability while mitigating personal financial risk.
Documentation Importance: Detailed and accurate patient records serve as a legal document, protecting nurses against claims of negligence and demonstrating accountability for care provided.
Advocacy: Nurses act as patient advocates by ensuring their rights are protected, their voices are heard, and they receive safe, ethical, and competent care. This involves understanding and applying legal and ethical principles.
Ethical Principles in Nursing
Autonomy: Respecting the patient's right to self-determination and to make informed decisions about their own health care, even if those decisions differ from what the nurse might recommend.
Beneficence: The ethical principle of acting in the best interest of the patient, doing good, and promoting their well-being. This often involves balancing potential benefits against risks.
Nonmaleficence: The fundamental ethical principle of "do no harm." Nurses must avoid actions that could cause harm and minimize risks to patient safety and well-being.
Justice: Ensuring fairness and equity in the distribution of health care resources, treatment, and decisions. This principle addresses issues of access, allocation, and non-discrimination.
The Relationship Between Ethics and Professional Practice
Responsibility: Nurses are morally and legally responsible for their actions and omissions in practice, upholding a commitment to patient welfare and professional standards.
Accountability: Beyond responsibility, accountability implies answering for one's conduct, particularly when standards of care or ethical principles are not met. This is reinforced by regulatory bodies and professional codes of ethics.
Advocacy: An ethical cornerstone of nursing, advocating involves protecting and articulating patient's rights and needs, especially when they are vulnerable or unable to advocate for themselves.
Moral Agency: Nurses are expected to be moral agents, meaning they have the capacity to recognize ethical issues, make principled judgments, and act on those judgments, even in challenging situations. This involves personal integrity and professional courage.
Consent and Information Rights
Importance of Informed Consent: Patients must provide voluntary consent after receiving full disclosure of information relevant to their treatment. This ensures respect for patient autonomy and upholds their legal right to self-determination.
Valid Consent Requirements:
The patient must be legally capable, meaning they have the mental capacity to understand the information and appreciate the consequences of their decision.
Consent must be voluntary, free from coercion or undue influence.
Consent must be informed, meaning the patient understands the nature of the treatment, its anticipated benefits, potential risks, and available alternatives (including no treatment).
Nurse's Role in Informed Consent:
Ensuring Understanding: Nurses are often responsible for reinforcing and clarifying information provided by the physician or primary practitioner. They assess the patient's comprehension and identify any gaps in understanding.
Witnessing Consent: Nurses may witness the patient's signature on a consent form, confirming that the patient signed voluntarily and appeared to understand the information.
Advocacy: If a nurse believes a patient does not fully understand, is being coerced, or is not legally capable, they have a professional and ethical duty to advocate for the patient, ensuring their rights are protected before consent is given.
Special Situations for Consent: Additional layers of considerations are required when dealing with patients who are legally incapable (e.g., minors, individuals with cognitive impairments) or when emergencies arise where consent cannot be readily obtained. In such cases, proxy consent or implied consent may be applicable, following specific legal guidelines.
Ethical Decision-Making, Moral Distress, and Moral Resilience
Principles of Ethical Decision-Making:
Identify the ethical problem: Clearly define the dilemma and the conflicting values or principles.
Gather relevant information: Collect all pertinent facts, including patient preferences, medical data, and legal/institutional policies.
Identify ethical options: Brainstorm and evaluate possible courses of action.
Apply ethical principles: Analyze each option through the lens of autonomy, beneficence, nonmaleficence, and justice.
Consult with colleagues/ethics resources: Seek guidance from ethics committees, colleagues, or other experts.
Choose and implement an action: Select the most ethically sound option and act on it.
Evaluate the outcome: Reflect on the decision's impact and learn from the experience.
Moral Distress: Occurs when a nurse knows the ethically appropriate action to take but is constrained by institutional, social, or personal barriers, preventing them from acting on their moral judgment. This can lead to feelings of frustration, anger, and powerlessness.
Moral Resilience: The capacity of a nurse to sustain or restore their integrity in response to moral adversity. It involves recognizing moral challenges, developing coping strategies, and maintaining commitment to core ethical values despite difficult circumstances. Strategies include self-care, seeking peer support, and advocating for systemic change.
Ethical Dilemmas in Clinical Practice and Resolution Strategies
Common Ethical Dilemmas:
End-of-Life Issues: Decisions regarding withholding or withdrawing life support, palliative care choices, and respecting patient autonomy in dying.
Medical Assistance in Dying (MAiD): Complex ethical and legal implications surrounding physician-assisted death, requiring careful consideration of patient suffering, consent, and legal frameworks (e.g., Carter v. Canada (AG)).
Resource Allocation: Deciding how to distribute limited resources fairly, particularly in situations of scarcity (e.g., critical care beds, organ transplantation).
Patient Confidentiality vs. Duty to Warn: Balancing a patient's right to privacy with the need to protect others from harm.
Conflicting Values: When a nurse's personal values conflict with a patient's wishes or institutional policies.
Strategies to Resolve Ethical Problems:
Utilize Ethical Decision-Making Models: Apply a systematic approach (as outlined above) to analyze and resolve dilemmas.
Consult Ethics Committees: Access institutional ethics committees or consultants for guidance and support in complex cases.
Interprofessional Collaboration: Discuss dilemmas with the healthcare team, including physicians, social workers, and other allied health professionals, to gain diverse perspectives and reach a consensus.
Advocate for Systemic Change: Address systemic factors that contribute to moral distress or recurring ethical dilemmas within the healthcare environment.
Professional Organizations and Guidelines: Refer to professional codes of ethics and practice guidelines from regulatory bodies to inform decision-making.
Self-Reflection and Peer Support: Engage in self-reflection and seek support from trusted colleagues to process challenging ethical situations and prevent burnout.