RN Engage 2.0 - Ethical and Legal Considerations

Code of Ethics and Nursing Profession

• All RNs and PNs must follow a Code of Ethics, which includes the ideals, duties, and obligations expected of nurses.
• Applies to licensed and student nurses in all client interactions, direct or indirect, including social media use.
• The International Council of Nurses (ICN) Code of Ethics is the basis for national codes, addressing clients, nursing practice, professional responsibilities, and global health.
• The updated 2021 ICN Code includes equity, social justice, climate change, technology, social determinants of health, and UN sustainable development goals.
• The ANA developed a document outlining rules for nurses about client privacy, nursing conduct, and behaviors to protect clients and the profession.
• The National Association for Licensed Practical Nurses (NALPN) has established Nursing Practice Standards for PNs.
• PNs must meet the ethical and moral obligations of nursing practice.
• The American Nurses Association (ANA) established the Code of Ethics for Nurses with Interpretive Statements.

Provisions of the Code of Ethics

• Provisions 1-3: Focus on the fundamental values of nursing and commitment to client care.
  • Compassionate care and respect for the client
  • Recognizing uniqueness, worth, and dignity of each client
  • Advocating for client rights and needs
  • Promoting and protecting health and safety
• Provisions 4-6: Focus on duty and loyalty to clients and themselves.
  • Demonstrating authority, accountability, and responsibility for best practices
  • Promoting health and providing the best possible care
  • Maintaining competence, practicing accepted values, and promoting a healthy and safe environment
  • Adhering to ethical principles
• Provisions 7-9: Focus on duty and loyalty beyond direct client encounters and to the profession.
  • Promoting the profession through research and inquiry
  • Participating in developing standards and policies
  • Collaborating to protect rights and decrease health disparities
  • Promoting integrity

Ethical Principles

• Autonomy: Respecting the client's right to make their own healthcare decisions, including refusal of care, unless harmful to others.
• Beneficence: Minimizing harm and acting in the client’s best interest, including providing extra care and implementing safety measures.
• Nonmaleficence: Obligation to do no harm, weighing potential benefits against risks.
• Veracity: Providing truthful and accurate information to strengthen trust.
• Fidelity: Demonstrating loyalty, keeping promises, and upholding commitments.
• Justice: Providing impartial, fair, and equitable care and resource allocation to all clients.

Values and the Nursing Profession

• Nurses use personal values and beliefs alongside ethical principles for ethical decision-making.
• Nurses should respect others’ values.
• The ANA says nurses should adhere to the values, moral norms and ideas of the profession and embrace them as part of what it means to be a nurse.
• Values are beliefs considered important, good, and meaningful, shaping behaviors and decisions.
• Professional values in nursing guide ethical practice, but the ANA's Code serves as a provisional guide.
• Valuing patient-centered care, confidentiality, respect for autonomy, compassion, professionalism, evidence-based practice, interdisciplinary collaboration, empathy, and lifelong learning ensures quality care and promotes positive health.
• The American Association of Colleges of Nursing created the Essentials of Baccalaureate Education for Professional Nursing Practice list.
• List narrowed focus to five professional values and behaviors in nursing from original broad range
• The Essentials includes altruism, human dignity, integrity, autonomy, and social justice
• Value clarification involves identifying, assessing, and developing personal values for ethical decision-making.

Five Core Professional Values in Nursing

• Altruism: Selfless concern for the benefit of others, prioritizing client interests, and demonstrating empathy.
• Human Dignity: Respecting the intrinsic value of each individual regardless of race, religion, or any other characteristic.
• Integrity: Demonstrating honesty and upholding professional standards, even when challenging.
• Autonomy: Respecting the client’s right to self-determination and healthcare decisions.
• Social Justice: Awareness of the basic right to health and well-being for every individual, advocating for equitable care.

Ethical Decision Making and Dilemmas

• Nurses need to apply ethical principles and values in practice.
• Ethical dilemmas involve conflicts of ethics and values without clear solutions.
• The Code of Ethics guides decision-making, regardless of personal beliefs.
• Ethical dilemmas require interprofessional collaboration and ethical decision-making processes.
• Ethical decision making is a process of evaluating and choosing options using ethical principles.
• Some facilities have ethics committees to address ethical dilemmas.

Steps in Ethical Decision Making

• Step 1: Identify if an ethical dilemma exists.
• Step 2: Clearly identify the ethical dilemma and those affected.
• Step 3: Identify all possible solutions.
• Step 4: Apply ethical principles to the solutions to identify advantages and disadvantages.
• Step 5: Include all relevant individuals and factors.
• Step 6: Decide on a solution, ensuring team agreement.
• Step 7: Review the decision for overlooked issues.
• Step 8: Put the solution into action with team collaboration and evaluation.

Nurses’ Role in Ethical and Legal Practice

• Ethical Issues: Nurses face difficult ethical situations that require ethical reasoning.
• Examples: stem cell research, late termination of pregnancy, medically assisted death, refusal or termination of care/treatment, care clients who have a substance use disorder, clients who have experienced abuse, care of clients in legal custody, and allocation of scarce resources.
• Ethical Practice:Prioritizes client safety and protection, guided by laws like EMTALA and HIPAA.
• Ethical Practice:Open and honest dialogue that examines the benefits and challenges of an ethical issue serves the profession well, as nurses continue to advocate for clients

Emergency Medical Treatment and Labor Act (EMTALA)

• EMTALA requires emergency medical personnel to provide equal care, regardless of insurance or financial status.
  • All clients must have a medical screening evaluation (MSE).
  • If the client is, in fact, experiencing an emergency, the hospital must stabilize the client.
  • If the hospital cannot provide the specific level of care (treatment and management) of the emergency condition, they must transfer the stabilized client to a facility that can.
  • In the event the client cannot be stabilized in said ED, a physician or another qualified medical professional must verify and sign off transfer, clearly indicating that the benefits of transfer outweigh the risks of transferring an unstable client.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

• HIPAA protects individuals' private health information and has a privacy rule.
• Only the client and involved healthcare workers have access to information.
• HIPAA protects all private health information, including electronic formats. Discussing client information is restricted to those directly involved in care.
• Privacy refers to physical seclusion and protection of personal information.
• Confidentiality refers to not disclosing personal information without permission.
• Violating HIPAA has legal and ethical consequences like fines, loss of license, and imprisonment.

Social Media and Confidentiality

• Nurses must avoid violating client confidentiality on social media, even in their personal lives
• Posting client information online can result in penalties, including termination.
• Principles for social networking directly related to the Code have been developed by the ANA.
  • Nurses should not transmit or post any identifiable client information.
  • Nurses should maintain professional boundaries if communicating with a client through social media.
  • Nurses should expect posted information to be potentially viewed by the client, peers, and supervisors.
  • Nurses should use privacy settings provided by social media platforms and attempt to keep personal versus professional information separate.
  • Nurses should advocate for client rights and report any instances of client information or communication on social media that is in violation of legal and ethical standards.
  • Nurses should work with their employer to develop effective policies and procedures to ensure professional communication with clients and to safeguard client information on social media.

Genetic Testing

• Genetic testing reveals unique genetic markings, with legal and ethical concerns.
• Legal issues include potential discrimination, but the Genetic Information and Nondiscrimination Act of 2008 protects against this.
• Ethical issues include respecting confidentiality and client autonomy.
• Nurses ensure clients understand information about genetic testing and coordinate referrals.

Criminal and Civil Law

• Nurses must adhere to standards of practice, and breaches can lead to legal action.
• Criminal law requires proof "beyond a reasonable doubt" and is used to punish and deter.
• Civil law addresses disputes and awards compensation. Nurses can face both criminal and civil cases.
• Criminal law usually has to prove there was intent to do harm and usually an error of action that led to harm.
• Lawsuits have become increasingly malpractice cases, with an error of omission, meaning that the provider should have done something.

Tort Law

• Tort law remedies harms from wrongful actions, compensating injuries and deterring harmful conduct.
• Unintentional torts include malpractice (failure to meet standards) and negligence (breaching duty of care).
• Malpractice insurance protects nurses from these risks.
• Intentional torts include assault and battery.

Informed Consent

• Informed consent requires providing relevant information to the client before obtaining permission for care.
• The provider performing the procedure or treatment is responsible for obtaining informed consent and must provide the client with the following information
  • The proposed treatment or procedure
  • Who will perform the treatment or procedure
  • The purpose of the proposed treatment or procedure
  • The expected outcomes of the proposed treatment or procedure
  • The benefits of the proposed treatment or procedure
  • The possible risks associated with the proposed treatment or procedure
  • The alternatives to the particular treatment or procedure
  • The benefits and risks associated with alternatives to the proposed treatment or procedure
  • The client’s right to refuse a proposed treatment or procedure
• Must be given voluntarily by a competent client or legal representative, without coercion.
• Nurses verify and witness the signature and confirm client knowledge.
• Minor Consent The legal ability of a minor to consent to health care services expanded over several decades due to several contributors including Title X

Implied Consent

• Unlike informed consent, implied consent does not require express verbal or written permission; it is assumed based on circumstances or actions.
• Clients give implied consent by allowing examination or treatment.
• Nurses must inform clients about planned actions; otherwise, it can be considered battery.
• It should be noted that, just like cases of informed consent, the client has the right to withdraw implied consent at any time.
• The client must have the mental capacity to provide such consent
• In emergencies, implied consent is assumed if a delay could pose a risk to the client.

Advance Directives

• Advance directives are legal documents that record a client’s healthcare decisions.
• There are 2 types.
  • Living will: which states life-sustaining treatments the client wishes to have done
  • Durable power of attorney: An individual is appointed to make health care decisions if the client cannot do it themselves

Good Samaritan Laws

• Protect nurses who provide aid in emergencies outside of employment, as long as they act reasonably and without gross negligence.
• Nurses must not know of the person's condition and cannot receive compensation.

Whistleblowing

• Whistleblowing is reporting illegal, unethical, or wrong actions within an organization to the appropriate agency.
• Federal and state safeguards protect whistleblowers.
• The ANA recommends seeking expertise from the board of nursing and legal counsel before reporting.

Mandatory Reporting

• Nurses are mandatory reporters of maltreatment and specific diseases.

Reporting of Maltreatment

• Maltreatment includes:
  • Physical, neglect, verbal, sexual, financial, educational
• Nurses must report suspected maltreatment to protect vulnerable individuals.

Reporting Incidence of Disease

• Reportable diseases:
  • Anthrax
  • Botulism
  • Chlamydia
  • Foodborne disease outbreak
  • Hepatitis A–C
  • HIV
  • Influenza
  • Measles
  • Rubeola
  • Tuberculosis
  • Zika virus
• Aims to monitor and prevent the spread of infectious diseases.

Reporting Incidents

• Incidents (unusual occurrences) can lead to a near-miss or sentinel events.
• Incident reporting is done to protect the client from further harm
• Must follow facility policies and complete reports promptly with objective language.

Reporting Should Include:

• Any event that is outside the routine care of a client, such as a medication error or a missed provider prescription
• Incidents involving workplace violence
• Any near-miss event, such as an expired medication that is identified before it is administered to a client
• Any adverse event that occurs to a client, staff member, or visitor, such as a fall
• Any sentinel event Although each facility has their own specific policies and forms for completing the documentation of an unusual occurrence, several rules apply regardless of the facility.
• This report the event to supervising staff immediately.
• Follow all facility policies regarding the documentation and reporting of the event.
• Complete the incident report as soon as possible following the incident.
• Can improve processes and is nonpunitive.

Just Culture

• Just Culture is accountability, reporting, and learning from mistakes

Legal Implications Related to Workforce Issues

• Awareness of state Nurse Practice Act can provide guidance

Client Abandonment

• Client abandonment can endanger a client for whom the provider has a prior relationship with,
• Includes leaving without arranging care, failure to provide report, and sleeping while assigned to care.
• Must have a reason for action.

Client-to-Nurse Staffing Ratios

• Increased ratios lead to increased client mortality rates, length of stay, and preventable incidents such as infections and falls.
• Shortages cause nurse burnout and dissatisfaction

Delegation

• Includes:
  • Right task
  • Right circumstance
  • Right person
  • Right directions and communications
  • Right supervision and evaluation

Breach of Nursing Practice

• It comes in several forms
• Failure to maintain standards of care, breaches in client confidentiality, and falsification of health records
• Factors include nurse fatigue and substance use disorder

Standards of Care

• Guidelines provided by the professional nurse by both professional performance and practice
• Nurses must uphold standards of care to maintain client safety and prevent breaches.
• Professional standards include ethics, cultural sensitivity, communication, collaboration, and leadership.
• Nurses should uphold this standard.

Lack of Confidentiality

• HIPAA violations have consequences for nurses, institutions, and clients, including disciplinary and legal penalties.
• Prevent breaches by avoiding discussions in public, securing passwords, logging out of computers, and avoiding social media references.

Falsification of Health Records

• Nurses must document accurately and truthfully.
• Falsification: Documenting inaccurate, incomplete, or misleading data can result in client harm and disciplinary action.

Nurse Fatigue

• Is the physical and psychological exhaustion
• Fatigue increases the risk of errors, breakdowns, and poor judgment.
• Nurse fatigue is attributed to many things, like long shifts and nursing staff shortages
• Measures include limiting shift lengths and hours worked per week; reducing night shifts to 8 hr; providing rest periods every 2 hr during the shift, including time for brief naps; and providing timed caffeine.

Substance Use Disorder Among Nurses

• Impaired nurses endanger themselves and their clients.
• Training to identify manifestations and reporting suspicions.
• Rehabilitation programs help nurses return to work safely.

Explore the Code of Ethics for RNs and PNs, including ideals, duties, and obligations. Covers ICN and ANA guidelines, addressing client interactions, professional responsibilities, equity, and social justice. Essential standards for ethical nursing practice.