Nursing Ethics & Legal Aspects of Nursing

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How do we perceive nurses?
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1. Most trusted profession (Gulp 2012). based on honesty & ethical standards 2. voted most ethical & honest profession in for 14 of the 15 years 3. 85% of Americans rated nurses’ honesty & ethical standards as “very high” or “high”, which is the highest rating for RNs since nurses were first included in the pool in 1999
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What ethics are not?
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-ethics has to do with what my feelings tell me is right or wrong -ethics has to do with my religious beliefs -being ethical is doing what the law requires -ethics consists of the standards of behavior our society accepts -i don’t know what the word means
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Ethics (some definition of)
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-refers to well-founded standards of right & wrong that prescribe what humans ought to do, usually in terms of rights, obligation, benefits to society, fairness or specific virtues -refers to the study & development of one’s ethical standards
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Ethics
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-is a branch of philosophy concerned with evaluating human action…it involves the principles & assumptions underpinning the way individuals or groups conduct themselves -a set of guidelines that can be applied logically
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personal values
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-enduring beliefs or attitudes about the worth of a person, object, idea or action (ex. belief about family, politics, work, religion), may be spoken or unconscious; underlie all moral dilemmas; influence decisions & actions including nurses’ ethical decision making
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values clarification
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-a process by w/c individuals identify, examine & develop their own value system: 1. choosing (cognitive)-belief are chosen freely from alternative, reflection & consideration of consequences 2. prizing (affective)-belief are prized & cherished 3. acting (behavior)-chosen belief are confirmed to others, incorporated into behavior consistently in one’s life
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Helping Patient w/ Values Clarification
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1. List alternatives 2. Examine possible consequences of choices 3. Choose freely 4. Feel good about the choice 5. Affirm the choice 6. Act on the choice 7. Act with a pattern
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slide # 12 Ethics?
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Nurses’ Professional Values
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Altruisim > autonomy > human dignity > integrity > social justice > (altruism)
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Moral Development
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-process of learning difference between right & wrong -begins in childhood & continues throughout life -moral development theories provide framework to view & clarify moral & ethical dilemmas
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Moral Issues Defined
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-arouse conscience -concerned with important values & norms evoke words such as good, bad, wrong, should & ought
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Moral Distress in Nursing
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-knowing what is appropriate, but being unable to act on it *study says “15% of nurses left their jobs because of moral distress” (recognize it & know your own values)
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Moral Principles
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-provide the foundation for moral rules about how we conduct our lives -the moral rule “people should not lie” is based on the principle of respecting others & on self-integrity
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Moral Principles of Bioethics
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>autonomy > nonmalificience > beneficience > justice > fidelity > veracity >
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Autonomy
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-the ability of a person to be self-determining & self-governing -the ability of a person to make choices based on information
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Beneficence & Non-maleficence
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-doing or promoting good; basis for all health care interventions -an extension of beneficence; avoid doing harm & to prevent harm; protective duty of health care providers
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Justice
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-fairness or obligation to treat all clients equally & fairly -foundation for decisions about resource allocation -medical need vs. ability to pay, social status, race, gender, or age
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Veracity
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-telling the truth is essential to the integrity of the client nurse relationship -the right to self-determination becomes meaningless if the client doesn’t receive accurate, unbiased, & understandable information -preferences can vary according to culture & related to sensitive issues (ex. disclosure) -demands specific communication skills & techniques
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Code of ethics
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-forma statement of a group’s ideals & values -serves as a standard for professional actions -provides ethical standards for professional behavior -shared by group members
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Nursing Code of Ethics
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-is a formal statement of a group’s ideal values -have higher requirements than legal standards
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ANA Nursing Code of Ethics (Revised January 2015)
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1. Respect the inherent dignity, worth & uniqueness of every individual 2. The nurses’ primary commitment is to the patient 3. The nurses’ promotes, advocates, & strives to protect the health safety & rights of the patient 4. The nurse is responsible & accountable for individuals nursing practice & determines the appropriate delegation of tasks 5. The nurse owes the same duties to self as to others: to preserve integrity & safety, to maintain competence & personal/professional growth 6. Participates in establishing, maintaining and improving healthcare environments 7. Participates in advancement of the profession through contributions to practice, education administration & knowledge development 8. Collaborates with other health professionals & the public to promote efforts to meet healthcare needs 9. The profession of nursing is responsible for articulating nursing values for maintaining the integrity of the profession, its practice & for shaping social policy
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Ethical Decision Making
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-know your own values & the ethical aspects of nursing -familiarize yourself w/ the nursing codes of ethics -seek continuing education -participate in hospital ethics committee -decision should be made systemically w/ reasoned input. Several good models to follow
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Tool for ethical decision making
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recognize an ethical issue > get the facts > evaluate alternative actions > make a decision & test it > act & reflect on outcome
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Ethical Behavior Can be Modeled
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-your ethics training should start now -think about how your behavior as a student reflects your ethical beliefs & principles -think about how your student colleagues perceive your behavior -are you the person who has excuses, twists the truth, or copies work? -your integrity is most valuable professional asset
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Milestone Ethical Cases
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-Karen Ann Quinlan- 1976; New Jersey Supreme Court permitted the removal of her ventilation at parents’ request
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Nancy Cruzan: Advance Health Directives
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-had car accidents > COMA > parents asked Doctors to remove her feeding tube > hospital refused, asked for court orders > Cruzan vs. Director, Missouri Department of Health > First Right to die case.
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Brittany Maynard (184-2014)
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-diagnosed w/ terminal brain cancer > moved to Oregon to take advantage of Oregon’s Death with Dignity Law > California passed the law on June 9, 2016 -Oregon, California, Washington, Vermont & New Mexico (has Death with Dignity Law)
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Case Studies
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SLIDES 34-39
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Nursing Practice Act
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California’s Nursing Practice Act defines an RN’s scope of practice in the State: RN.gov -be familiar w/ Nursing Act for each State, there are differences
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Carrying out Physician’s Order
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-nurses are expected to analyze procedures & medications ordered by the physician & perform the practice based on the analysis. The RN is required : 1. Question any order a client questions 2. Question any order if the client’s condition has changed 3. Question & record verbal orders to avoid miscommunications 4. Question any order that is illegible, unclear, or incomplete
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Use your chain of command: If you disagree w/ physician order
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1. contact the physician & discuss 2. escalate as appropriate to your charge nurse, manager or the physician’s supervisor 3. document your actions, reasoning, and who you discussed the matter with
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Informed consent (what to do?)
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-nurse must insure the client gave consent voluntarily -the signature is the patient’s -the client appears competent to consent -(language barriers, LOC, sedation, etc. must be assessed)
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Patient self-determination: Federal Patient Self-Determination Act of 1990
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-requires healthcare institutions that receive federal funds provide adults patients w/ written information on Advance Directives -Institutions cannot discriminate against patients that have DNR or other orders -institutions have an obligation to educate the community about advance directives
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Advance Health Care Directives
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-Includes a variety of legal & lay documents that allow person to specify aspects of care they wish to receive when they become unable to make or communicate their preferences -Living Will:Provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decision -Durable Power of Attorney for Health Care (Health Care proxy); a notarized or witnessed statement appointing someone else to manage health care treatment decisions
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Case Studies 2
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SLIDES 48
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informed consent
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-an agreement by a client to accept a course of treatment or procedure after being provided complete information, including the benefits & risks of treatment & prognosis if not treated by a health care provider -two types: express content (oral or written) & implied consent (non-verbal behavior) -the physician has the responsibility to obtain the consent, though the RN often obtains the signed consent form -is the patient competent? Medications on boards, dementia, language etc. -assess “health literacy” is a patient really informed if they don’t understand the jargon or risks? -culturally competent care is required. Translator to overcome language barriers -right of consent involves right of refusal, at any time
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informed consent exceptions
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1. minors can consent for procedures such as blood donations, treatment for substance abuse, treatment for mental health problems, & for reproductive health concerns such as sexually transmitted disease or pregnancy 2. If a patient is unconscious or injured & is therefore unable to give consent, consent can be obtained from the closest adult relative for the client’s emergency condition. Physician if no one available. 3. Mentally ill persons who have been judged by professionals to be incompetent
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Health Insurance Portability & Accountability Act (1996) HIPAA
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-The first Nationwide legislation to protect privacy for health information
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Examples of HIPAA Compliance & Nursing Practice
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1. A client’s name cannot be posted near or on the door room 2. Charts should be in a secure, nonpublic location to prevent public from viewing or accessing confidential health information 3. Printed copies of protected health information should not be left unattended at a printer of fax machine 4. Access to protected health information (PHI) is limited to those authorized to obtain the information 5. Health care providers will need a password to access a client’s electronic chart 6. A notice informing clients of their rights about privacy & their health information should be posted or provided 7. Voice level should be lowered to minimize disclosure of information 8. Health care providers must stay current with HIPPA regulations
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Patient’s Right to Access
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1. Access- only you or your (personal representative) has the right to access your records. A HCP or health plan may send copies of your records to another provider or health plan as needed for treatment or payment or as authorized by you 2. Provider’s Psychotherapy Notes- you do not have the right to access a provider’s psychotherapy notes. Psychotherapy notes are notes taken by mental health professional during a conversation with the patient & kept separate from the patients medical & billing records 3. Correcting information-if you think in you medical or billing record incorrect, you can request that the health care provider or health care plan amend the record. The HCP or health plan must respond to your request
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Protected Health Information (PHI)
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-18 different identifiers: Name, address, IP address, any unique identifier -any information about health status, provision of health care, or payment for health care that can be linked to specific individual. This is interpreted rather broadly & includes any part of a patient’s medical record or payment history
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Areas of Potential Liability in Nursing
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1. Negligence 2. Malpractice 3. Assault 4. Battery 5. False imprisonment 6. Invasion of privacy 7. Defamation 8. HIPAA privacy violation
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Negligence
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-is misconduct or practice that is below that standard expected of an ordinary, reasonable, & prudent person
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Malpractice
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-is professional negligence occurred while the person was performing as a professional
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Assault
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-is an attempt or threat to touch another person unjustifiably. A nurse who threatens a client with an injection after the client refuses to take medication orally would be a committing assault
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Battery
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-is the willful touching of a person (or something the person is carrying) without permission
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To Prove Malpractice: (malpractice)
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-A patient must show a wrong occurred because of a professional’s failure to act as a reasonable & prudent professional would have acted in the same situation
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3 characteristics of malpractice (malpractic)
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1. the person must be working in a professional capacity (either paid or volunteer) 2. the wrong must be demonstrated 3. the wrong must be shown to have been caused by the failure of the professional to act as a reasonable & prudent member of that profession
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False imprisonment
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-is the unjustifiable detention of a person w/o legal warrant to confine the person. Ex. is a forceful restraint or confining of a client in the hospital. The client should be able to leave by signing an AMA (against medical advice) form.
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Invasion of Privacy
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-breaking the right to privacy & the right to be left alone. Ex. passing confidential information to not authorized people intruding into the client’s private domain or unnecessary discussion about the client
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Defamation
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-is communication that is false or made with a careless disregard for the truth & results in injury to the reputation of a person. It includes libel (writing, picture, print) & slander (spoken)
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Slander examples
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-treat others as you would want to be treated (professionalism means you don’t have to join in bad behavior)
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1. Following a motor vehicle accident, the parents refuse to permit withdrawal of life support from their child w/ no apparent brain function. Although the nurse believes the child should be allowed to die & organ donation should be considered, the nurse support their decision. Which moral principle provides the basis for this nurse’s action?
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Respect for autonomy
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2. Although the client refused the procedure, the nurse insisted & inserted a nasogastric tube. Later, the client sued the RN. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of w/c of the following?
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Assault & Battery
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3. A nurse’s spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which of the ff practices is the most appropriate in terms of HIPAA regulation?
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4. Which of the following is an example of a HIPAA violation?
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Handing a patient someone else’s medical card
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5. 77 year old woman w/ an inoperable brain tumor has been hospitalized for the past 5 days. Her daughter comes to visit her. The pt has asked that her daughter not be told her diagnosis. After visiting w/ her mother, the daughter asks to speak to the nurse. She says, “My mother claims she has pneumonia, but I know she is not telling me the truth.” The daughter asks the nurse to tell her what is truly wrong with her mother. The nurse should tell her that:
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3. her mother requested that her case not be discussed with anyone, not even family

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