Week 1: Legal and Ethical Considerations in Nursing

Legal and Ethical Considerations

• Legal framework for regulated health professions in Ontario is governed by the Regulated Health Professions Act (RHPA) and Nursing Act.
• The College of Nurses of Ontario (CNO) regulates scope of practice for nurses.
• Controlled acts are those considered potentially harmful if performed by unqualified individuals.
• 5 out of 14 acts are authorized for nurses when ordered.
• Specific controlled acts include procedures below the dermis/mucous membrane, administering substances (injection/inhalation), inserting instruments/fingers beyond body orifices, dispensing medications (new for RPNs), and treatments using psychotherapy.
• Authorizing mechanisms include written orders (client-specific) and directives (pre-existing, group-specific). Just because a nurse is authorized to administer a medication, doesn't mean it's always appropriate.
• Orders are required for certain controlled activities, like injections, inhalations, procedures below the skin, inserting instruments beyond body openings, drug dispensing, and parts of medical procedures (e.g., lab tests and X-rays).
• The Canadian Food and Drug Act governs foods, drugs, cosmetics, and medical devices. Drugs must comply with official standards and recognised formularies.
• Prescription drugs are categorized by schedule.
• Non-prescription (OTC) drugs have "open access", "open access/scheduled", and "restricted access/scheduled" categories. Access and use conditions vary based on schedule.
• Non-narcotic prescription drugs (Schedule F) can only be prescribed and refilled by qualified health professionals (doctors, dentists, etc.).
• The Controlled Drugs and Substances Act (CDSA) replaced the Narcotic Control Act. It regulates the control and sale of narcotics and other controlled substances. The letter "C" is printed on their respective labels.
• Restrictions for narcotics include limited possession, security measures, required reporting for loss/theft, and record keeping. They are frequently dispensed by prescription for a set period before reassessment.
• Legal possession of narcotics for nurses typically applies when administering with a doctor's orders, acting as a custodian (in a health care setting), and for prescribed medical treatments.
• Managing narcotics involves keeping them locked, maintaining strict documentation (e.g., counts; co-signing waste procedures), and establishing timeframes for reviewing prescriptions.

Drug Standards

• Drug purity involves specifying acceptable types and concentrations of impurities (e.g., dyes, flavorings).
• Drug potency refers to standardized drug strength.
• Drug bioavailability is the degree to which the body absorbs and transports a drug to its site of action.
• Drug efficacy describes how effective a drug is.
• Drug safety is assessed through incidence and severity of documented adverse reactions.

Sources of Drugs

• Drugs can be derived from plants, animal products, inorganic compounds or synthetic sources.

New Drug Development

• Drug research and development is a continuous process, and the Canadian system is one of the most stringent globally.
• The process was developed in response to concerns about patient safety and efficacy.
• Natural Health Products Regulation (2004) and Health Canada approval process are key parts.
• Approved drugs receive a unique Drug Identification Number.

Four Clinical Phases of Investigational Drug Studies

• Phase I studies involve a small number (fewer than 100) of healthy subjects.
• Phase II uses larger numbers of patients with specific diseases or conditions (100-300).
• Phase III involves larger numbers of patients (1000-3000), tracking results over extended periods.
• Phase IV studies occur after drug release (voluntarily by the companies) to obtain further information on overall therapeutic and adverse effects.

Special Access Programme

• A special access programme allows compassionate access for health care providers to drugs not available for sale in Canada.
• The criteria for this programme includes patients with serious or life-threatening conditions where other treatments have failed or are inappropriate or unavailable.

Patient Access and Costs of Prescription Drugs

• High drug expenses are a significant barrier for medication access, especially for low-income individuals, those without drug benefits, and those with poor health.
• These individuals often experience marginalization and lower socioeconomics status.

Legal Nursing Considerations

• Nursing practice must adhere to standards of care and scope of practice guidelines, and consider case law, common law.
• The Canadian Nurses Association (CNA) provides a national voice for registered nurses.
• Accreditation Canada necessitates accredited hospitals to follow nursing standards.

Areas of Potential Liability

• Nurses can be held liable for negligence, malpractice, failure to properly assess patients, failure to ensure safety, and medication errors.

Ethical Considerations

• Ethical principles guide healthcare providers' actions, encompassing autonomy, beneficence, non-maleficence, justice, fidelity, and veracity.
• The CNA Code of Ethics and the International Council of Nurses (ICN) Code of Ethics for Nurses are relevant frameworks
• ethical care includes safety, compassion, competence, care. Also, health promotion, dignity, informed decision making, privacy, and confidentiality are fundamental aspects of ethical practice

Right of Nurse to Refuse Care

• Nurses have the right to refuse care if it violates their personal ethical principles.
• The nurse has a responsibility to speak to their supervisor or manager, and must not abandon the patient.
• Nurses are responsible for providing non-judgemental care and always act in the patient's best interest while remaining as an objective advocate.

Practice Questions (Case Studies)

• A nurse faced with performing an elective procedure violating their ethical principles should speak to a manager or supervisor instead of performing the procedure; refusing or swapping assignments.
• A research participant who desires to withdraw from a study should be supported by exploring their reasons for doing so and acknowledging their right to withdraw.
• A nurse who fails to notice worsening IV site conditions is demonstrating a failure to assess the patient's safety needs.

Nursing Process

• The nursing process is a research-based framework for professional nursing practice.
• It emphasizes flexibility, adaptability , and a systematic method to deliver high-quality care to patients. This framework uses critical thinking and clinical judgment. This is an evolving process.
• The nursing process has five steps.

Assessment

• Data collection, review, and analysis are essential parts of the assessment process.
• Documentation of the patient's medication profile, including any and all current drug usage, home remedies, alcohol, tobacco, caffeine intake, prescription meds, over-the-counter meds, past/present health history, family history, growth and developmental stage, and issues related to age and medication.

Nursing Diagnoses

• A three-step process is used to determine nursing diagnoses with respect to the patient's response to illness or injuries leading to a change (with factors "related to"), specific problems requiring care.

Specific Nursing Diagnoses related to drug therapy.

• Deficient knowledge of the patient's drug therapy regimen.
• Risk of injury resulting from the patient's drug therapy.
• Nonadherence to the prescribed treatment plan.
• Various issues related to the patient's bodily function that stem from their drug regimen.
• Other problems or concerns stemming from the patient's drug regimen.

Planning

• Establishing goals and outcome criteria as part of the planning phase is essential. The criteria should be specific, measurable, attainable, realistic, and time-bound.
• Describing concrete descriptions and plans for patient goals required.

Implementation

• Implementation involves the nurse initiating and completing actions dictated by nursing diagnoses, goals, and outcome criteria.
• This includes independent, collaborative, and dependent interventions. These must clearly outline frequency and specific instructions.

Evaluation

• Evaluation is a systematic and ongoing part of the dynamic nursing process. The status of patient goals and outcomes of care are monitored. The nurse monitors the patient's response to drug therapy, considering both therapeutic, expected, and toxic responses.
• Documentation must be clear and concise.