Legal and Ethical

Source of Law

-Statutory Law: created by state legislators and U. S. Congress -> Nurse Practice Act: 1. Defines the legal boundaries of nursing practice within a state 2. Expanded nursing role 3. Educational requirements 4. Differentiates Nursing practice from Medical practice Nurse lobbyist help them understand the nurse profession. Each state has nurse practice act. If you don't know the nurse practice act or you are liable for not knowing the practice act.

Risk Management and Quality Assurance

- Areas of Potential Risk: *Electrical hazards *Electronic monitoring *Operating room (Time-Out) - Never Events (preventable events) *Falls *Urinary tract infections from catheters *Pressure ulcers The federal government and health care insurance companies have policies to withhold reimbursement for preventable medical errors

Licensure

- State Board of Nursing or Nursing Commission licenses all RNs in the state in which they practice. - The requirements for licensure vary among states. All states use the NCLEX for RNs and licensed practical nurse examinations. - Licensure permits people to offer special skills to the public, and it also provides legal guidelines for protection of the public. - The State Board of Nursing suspends or revokes a license if a nurse's conduct violates the Nurse Practice Act. - A license is a property right, the State Board of Nursing must provide notice and follow due process before revoking or suspending a license. Due process means that the state is required to notify nurses of the charges brought against them. - Actions and decisions by State Boards of Nursing are published and accessible by health care agencies and the general public. - Renewal every 2 years Caught DUI or Drug use then it gets reported to board of nursing.

Do Not Resuscitate (DNR)

- "Do not resuscitate" (DNR) or "no code" DNR order. Documentation that the health care provider has consulted with the patient and/or family is required before attaching a DNR order to the patient's medical record. - The health care provider needs to review DNR orders routinely in case the patient's condition demands a change. - CPR is an emergency treatment provided without patient consent. The statutes assume that all patients will be resuscitated unless there is a written DNR order in the medical record. You can make it specific as possible. Need to be signed by the physician, They usually put it in the freezer for the DNR. If you don't have the sign form of DNR you have to be aggressive. You have to ask patient if they want to still keep the DNR and if the information if accurate. DNR needs to be in the medical record or can be charged.

Abandonment

- Abandonment of a patient occurs when a nurse refuses to provide care for a patient after having established a patient-nurse relationship. - Before having established that relationship, a nurse may refuse an assignment when: * the nurse lacks the knowledge or skill to provide competent care * care exceeding the Nurse Practice Act is expected * health of the nurse or her unborn child is directly threatened by the type of assignment * orientation to the unit has not been completed and safety is at risk * the nurse clearly states and documents a conscientious objection on the basis of moral, ethical, or religious grounds * the nurse's clinical judgment is impaired as a result of fatigue, resulting in a safety risk for the patient

Advanced Directives

- Advance directives include living wills, health care proxies, and durable powers of attorney for health care. They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over the dying process. - Living Wills. Represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. - Health Care Proxies or Durable Power of Attorney for Health Care. A health care proxy or durable power of attorney for health care (DPAHC) is a legal document that designates a person or people of one's choosing to make health care decisions when a patient is no longer able to make decisions on his or her own behalf. - Children are generally innocent third parties. Although the courts will not force adults to undergo treatment refused for religious reasons, they will grant an order allowing hospitals and health care providers to treat children of abusive or negligent parents or groups who have denied consent for treatment of their minor children for religious reasons. This is based on the legal doctrine of parens patriae in which the state or government makes decisions on behalf of those who are unable to make decisions for themselves.

Informed Consent

- Informed consent is a patient's agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences of refusal. - Requires a health care provider to disclose information in terms a patient is able to understand to make an informed choice. - Failure to obtain consent in situations other than emergencies can result in a claim of battery. - Informed consent is part of the health care provider-patient relationship. It must be obtained and witnessed when the patient is not under the influence of medication such as opioids. - It does not fall within the nurse's responsibility. The person responsible for performing the procedure is responsible for obtaining the informed consent. - Key elements of informed consent include the following: (1) the patient receives an explanation of the procedure or treatment; (2) the patient receives the names and qualifications of people performing and assisting in the procedure; (3) the patient receives a description of the serious harm, including death, that may occur as a result of the procedure and anticipated pain and/or discomfort; (4) the patient receives an explanation of alternative therapies to the proposed procedure/treatment and the risks of doing nothing; (5) the patient knows that he or she has the right to refuse the procedure/treatment without discontinuing other supportive care; (6) the patient knows that he or she may refuse the procedure/treatment even after the procedure has begun. Patients with mental illnesses must also give consent. They retain the right to refuse treatment until a court has determined legally that they are incompetent to decide for themselves.

Medical Malpractice Insurance

- Nurses employed by health care agencies are covered by insurance provided by the agency; remember the lawyer is representing the employer and not you. - The insurance provided by the employing agency only covers nurses while they are working within the scope of their employment. - Nurses are also investigated by the State Board of Nursing or Nursing Commission to determine if the alleged breach in care violated the Nurse Practice Act. - The nurse will be required to personally pay all costs and attorney fees incurred by him or her in the defense against these claims.

Care Providers Orders

- Nurses follow health care providers' orders unless they believe that the orders are in error or are harmful to the patient. - Clarification from the health care provider is necessary. - If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command. - A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the patient suffers. - Written orders, verbal orders, telephone orders Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Therefore you need to assess all orders; if you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor. The supervising nurse should help resolve the questionable order. A medical consultant sometimes helps clarify its appropriateness or inappropriateness. A nurse carrying out an inaccurate or inappropriate order is legally responsible for any harm the patient suffers. In a malpractice lawsuit against a health care provider and a hospital, one of the most frequently litigated issues is whether the nurse kept the health care provider informed of the patient's condition. To inform a health care provider properly, you perform a competent nursing assessment of the patient to determine the signs and symptoms that are significant related to the attending health care provider's tasks of diagnosis and treatment. Be certain to document that you notified the health care provider and his or her response, your follow-up, and the patient's response. Make sure that all the health care provider orders are in writing, dated and timed appropriately, and transcribed correctly. Verbal or telephone orders are not recommended because they leave the possibilities for error. If a verbal or telephone order is necessary during an emergency, it is signed by the health care provider as soon as possible, usually within 24 hours (TJC, 2016). You're legally responsible for caring out the provider's order. If its order for surgery or DNR ,then two nurse is required.

Nursing Students

- Nursing students are liable if their actions exceed their scope of practice and cause harm to patients. - If a student harms a patient as a direct result of his or her actions or lack of action, the student, instructor, hospital, or health care agency and the university or educational institution generally share the liability for the incorrect action. - Nursing students should never be assigned to perform tasks for which they are unprepared, and instructors should supervise them carefully as they learn new skills.

Restraints

- Physical restraint is any manual method, physical or mechanical device, material or equipment, or chemical (medication) that immobilizes or reduces the ability of a patient to move freely. - The use of restraints has been associated with serious complications and even death. You need to know when and how to use and safely apply restraints. - Restraints can be used (1) only to ensure the physical safety of the patient or other patients (2) when less restrictive interventions are not successful (3) only on the written order of a health care provider. - Regulations describe documentation of restraint use and follow-up assessments. - Litigation from improper restraint use is a common nursing legal issue. Every 24 hour the documentation needs to be renewed.

Health Insurance Portability and Accountability Act (HIPAA)

- Portability: protects individual employees from losing their health insurance when changing jobs by providing portability. - Accountability: Privacy: the right of patients to keep personal information from being disclosed Confidentiality: protects private patient information once it is disclosed in health care settings, it is a sacred trust Nurses help organizations protect patients' rights to confidentiality

Risk Management and Quality Assurance

- Risk-management and quality improvement programs are the development of an organizational system of ensuring appropriate, quality health care by identifying potential hazards and eliminating them before harm occurs. - Incident reports provide a database for investigation to determine deviations from standards of care, identify corrective measures needed to prevent recurrence, and to alert risk management to a potential claim situation. - Incident reports are confidential and separate from the medical record; however, they are discoverable during a legal proceeding. Nurses are responsible for providing information in the medical record about an occurrence (only facts). Never document in the patient's medical record that you completed an occurrence report. - A nurse's documentation is the evidence to support that the nurse acted reasonably and safely. The nurse's assessments and the reporting of significant changes in the assessments are very important factors in defending a lawsuit. It is critical to document the health care provider contacted, the information communicated, and the health care provider's response

Legal Limits of Nursing

-Professional Standards: Knowing professional standards allows you to be a client advocate and protect the client from harm you need to understand the legal limits of nursing and the professional standards of care that affect nursing practice. Knowledge of these responsibilities allows you to be a patient advocate and protect patients from harm. Protect the patient.

The Informed Consent

- The nurse's signature as a witness to the consent means that the patient voluntarily gave consent, the patient's signature is authentic, and the patient appears to be competent to give consent. - When nurses provide consent forms for patients to sign, they must ask the patients if they understand the procedure for which they are giving consent. If patients deny understanding notify the health care provider or nursing supervisor. Health care providers must inform a patient refusing surgery or other medical treatment about any harmful consequences of refusal. If the patient continues to refuse the treatment, the nurse should again ensure that documentation of the rejection is written, signed, and witnessed. - Nursing students cannot be responsible for or asked to witness consent forms because of the legal nature of the document. - Parents are usually the legal guardians of pediatric patients; they typically sign consent forms for treatment. Occasionally a parent or guardian refuses treatment for a child. In these cases the court sometimes intervenes on the child's behalf. Courts generally consider the child's ultimate safety and well-being as the most important factors. - If a patient is unconscious, you must obtain consent from a person legally authorized to give it on the patient's behalf. - Patients with mental illnesses must also give consent. They retain the right to refuse treatment until a court has determined legally that they are incompetent to decide for themselves.

Professional Organizations

- The voice of nursing is powerful and effective when the organizing focus is the protection and welfare of the public entrusted to nurses' care. - Become involved in professional organizations and committees that define the standards of care for nursing practice. Become involved in professional organizations and committees that define the standards of care for nursing practice. If current laws, rules and regulations, or policies under which nurses practice are not evidence based, advocate to ensure that the scope of nursing practice is defined accurately. Be willing to represent nursing and the patient's perspective in the community as well. The voice of nursing is powerful and effective when the organizing focus is the protection and welfare of the public entrusted to nurses' care

Torts

- Torts are civil wrongful acts or omissions made against a person or property. - They are classified as: (1) Intentional: deliberate acts that violate another's rights such as assault, battery, and false imprisonment. (2) quasi-intentional: acts in which intent is lacking but volitional action and direct causation occur such as in invasion of privacy and defamation of character (3) Unintentional: unintentional tort, which includes negligence or malpractice. Nursing practice is also regulated by common law or judicial case law of torts. Torts are civil wrongful acts or omissions made against a person or property. They are classified as intentional, quasi-intentional, or unintentional. Intentional torts are deliberate acts that violate another's rights such as assault, battery, and false imprisonment. Quasi-intentional torts are acts in which intent is lacking but volitional action and direct causation occur such as in invasion of privacy and defamation of character. The third classification of tort is the unintentional tort, which includes negligence or malpractice.

Safe & Competent Nursing Practice

-Clinical reasoning -Understanding of the legal framework of health care, nursing practice Safe and competent nursing practice requires clinical reasoning and an understanding of the legal framework of health care, the specific state's Nurse Practice Act, and the scope and standards of nursing care. Frequently nurses practice under several sources and jurisdictions of health care law simultaneously. Understanding the legal implications of nursing practice demands clinical judgment skills to protect patient's rights and the nurse from liability. Society expects safe health care delivery, especially from nurses who typically are perceived as being part of the most ethical and trusted profession. As patient care practice innovations and new health care technologies emerge, the principles of negligence and malpractice liability are being applied to challenging new situations. Thus you need to practice nursing armed with the skills that are the outcomes of informed critical thinking.

Standards of Care

-Legal requirements for nursing practice that describes minimum acceptable nursing care -Developed by the American Nurses Association. -Described in the State Nurses Practice Act, Federal and State Laws, health care agencies, and professional organizations Have steps that we need to follow to do standard of care. Those standard is based on Evidenced based care. It has given the best patient outcome. Substandard care then patient suffer and we get in trouble.

4 Source of Law

1. Administrative Law: Decision makers are the State Boards of Nursing (i.e. reporting unethical practice) 2. Common Law: Decision makers are the courts (i.e. patient's right to refuse treatment, negligence, and malpractice) 3. Civil Law: Protect the rights of the people, consequences are fines or public service (i.e. nursing negligence) 4. Criminal Law: Protect society as a whole, and provide punishment for crimes, (i.e. with nursing, misuse of controlled substances and practicing without a license) CivilLaw doesn't go to imprisonment. If the nurse sells narcotics then it can go to criminal Law.

Professional Organizations

Become involved in professional organizations and committees that define the standards of care for nursing practice.

Nurse's Conduct

In a malpractice lawsuit a nurse's actual conduct is compared to nursing standards of care to determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances. One nurse acted and compared to how the other nurse would act in that circumstances=prudent nurse. Comparing to ideal nurse to the subject nurse/ comparing with their peers. Needs to be standard patient care.

Technology

Issues with: Social media Cameras Electronic charting

Proof of Negligence

Proof of Negligence: - The nurse owed a duty of care to the patient. - The nurse did not carry out the duty or breached it (failed to use that degree of skill and learning ordinarily used under the same or similar circumstances by members of the profession). - The patient was physically injured. - The patient's injury resulted in compensable damages that can be qualified as medical bills, lost wages, and pain and suffering. - The patient's injury was caused by the nurse's failure to carry out that duty.

Organ Donations

Uniform Anatomical Gift Act - An individual who is at least 18 years of age has the right to make an organ donation. - In most states Required Request laws mandate that, at the time of admission to a hospital, a qualified health care provider has to ask each patient over age 18 whether he or she is an organ or tissue donor. - In most states there is a law requiring that at the time of death a qualified health care provider ask a patient's family members to consider organ or tissue donation. - Individuals are approached in the following order: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian. The person in the highest class makes the donation unless they are aware of conflicting indications by the decedent. - The health care provider who certifies death is not involved in the removal or transplantation of organs. - The National Organ Transplant Act (1984) prohibits the purchase or sale of organs. The act provides civil and criminal immunity to the hospital and health care provider who perform in accordance with the act. The act also protects the donor's estate from liability for injury or damage that results from the use of the gift. - Patients who require organ transplantation are on a waiting list for an organ in their geographical area that gives priority to patients who demonstrate the greatest need. Brain death no brain activity and there is all paper work in order for the donation to happen. If they are candidates then the family needs to be approached. If you're not as a nurse feel comfortable to approach patient's family then there are special members that do it for you. If patient dies by law they need to call the organ donor and get a code that they are not a candidate.