Exam 11 - Legal and Ethical

Legal Principles & Ethical Standards in Nursing Practice

• Legal principles and ethical standards guide LPN/LVN nursing practice.
• Nurse Practice Acts, established in each state, determine the scope of nursing practice.
• Ethical principles, influenced by societal and cultural norms, often impose higher duties than legal standards.

Overview of the Legal System

• Laws dictate proper behavior and consequences for unacceptable behavior.
• Nurses require a fundamental understanding of the legal system.
• The legal system assigns duties and provides protection for healthcare professionals.

Types of Law

• Criminal Law: Deals with public offenses, leading to verdicts of guilty or innocent.
• Civil Law: Involves disputes between individuals, resulting in accountability or innocence and potential monetary settlements.
• Statutory Law and Common Law: Developed by government bodies in response to legal questions, often based on precedents.

Negligence

• Negligence: Absence of due care, often characterized by carelessness.
• Nurses and UAP can be held accountable for negligence.
• Negligence involves failure to act with the care and knowledge expected of any prudent individual.
• Examples: medication errors, patient falls, use of restraints, equipment injuries.

Malpractice

• Malpractice: Professional negligence with four key elements:
  • Duty: Established relationship between patient and nurse.
  • Breach of Duty: Failure to perform the duty in a reasonable manner.
  • Harm: Can include physical injury or other forms of harm.
  • Proximate Cause: The breach of duty directly caused the harm.
• Malpractice may result in legal punishment or restitution.
• Best practices for avoiding malpractice: adhering to regulations, standards of care, and facility policies.

Legal Relationships

• Individuals, facilities, staff, and departments can be held liable for alleged harm.
• Nurses face increased responsibilities and potential legal actions.
• Accountability: Nurses are legally responsible for their actions.
• Increasing litigation against nurses due to factors like:
  • Increased responsibilities and technological advancements.
  • Staffing shortages and budgetary constraints.
  • High patient acuity and early discharge.
• Common areas of litigation: standards of care, equipment use, documentation, and patient advocacy.

Nurse-Patient Relationship

• Duty to Provide Professional Care: The nurse-patient relationship initiates a legal obligation to provide care.
• Patient Advocacy: Nurses are obligated to protect patient interests, both legally and ethically.

Regulation of Practice

• Standards of Care: Define acts that are required, permitted, or prohibited.
  • Derived from federal and state laws, regulations, and professional organizations like the ANA.
  • Failure to adhere to these standards can lead to legal liability.
  • Nurses must seek additional instruction and supervision when unfamiliar with a practice or procedure.

Nurse Practice Acts

• Define and limit the scope of nursing practice.
• Each state, province, and territory has its own nurse practice act.
• Employing institutions may set additional limitations within the confines of the state's nurse practice act.

Legal Issues

• Patient Rights: Patients have expectations regarding their healthcare, outlined in The Patient Care Partnership.
• Joint Commission: Accredits and certifies healthcare facilities.
• Patient Self-Determination Act: Requires facilities to provide information on advance directives and treatment choices.
• HIPAA: Protects patient health information, sets regulations for accessing and disclosing patient data.
• Health Care Institution Obligations: Provide access to care without prejudice, treat patients with respect and dignity, ensure privacy and confidentiality, and maintain personal safety.
• Patient Responsibilities: Provide accurate information, participate in decision-making.

Informed Consent

• Informed Consent: Patients are informed about treatment options and risks before invasive procedures.
• Failure to obtain informed consent can result in civil liability.
• Patients can withdraw or limit consent at any time.
• Consent must be provided by the appropriate person (e.g., legal guardian for minors).
• Competence: Patients must be of sound mind to provide consent.
• The nurse's role in consent: witnessing the patient's signature, not providing information.

Confidentiality

• Nurses are legally obligated to protect patient information.
• Confidentiality violations can lead to legal liability, disciplinary action, and even criminal charges.
• Secured information storage, private conversations, and appropriate access to electronic records are crucial.
• Protected health information (PHI): includes identifiers beyond name and social security number.

Social Media

• Social media can be a valuable tool for nurses, but there are risks.
• Facilities have policies regarding smartphone and handheld device use.
• Social media violations often involve blurring boundaries with patients or discussing confidential information.
• Violations can result in disciplinary action, including license sanctions.

Medical Records

• Laws and facility policies govern medical records.
• Records are not public documents, and confidentiality must be maintained.
• Information in medical records can be used in legal cases to support claims.

Documentation

• Accurate documentation is a key defense against legal claims related to nursing care.
• Thorough documentation protects the nurse by documenting the care provided.
• Charting by exception allows for quicker documentation, focusing on deviations from standard care and progress notes.
• Incident Reports are used to document unplanned events in a healthcare facility, promoting learning and preventing future problems.
• Information in incident reports should be objective and factual.
• Incident reports shouldn't be included in the patient's medical records.

Communication

• Effective communication is crucial in nursing, involving both verbal and nonverbal aspects.
• Verbal Communication involves spoken or written words, but interpretations may vary.
• Nurses should use clear, common language to prevent misunderstandings.
• Nonverbal Communication includes tone of voice, volume, eye contact, touch, and physical appearance.
• Eye contact varies across cultures, but can convey interest or disinterest.
• Maintaining a professional appearance demonstrates self-respect and competence.

Therapeutic Communication Techniques

• Therapeutic communication focuses on building a positive nurse-patient relationship.
• Active listening requires full attention to the patient's message and allows for validation.
• Silence provides time for reflection and processing.
• Touch can convey warmth, comfort, and support, with culturally appropriate use.
• Conveying Acceptance builds trust by accepting the patient's values and beliefs without judgment.
• Minimal encouragement shows the nurse is interested and attentive.
• Open-ended questions allow for elaboration and exploration.
• Restating confirms understanding of the patient's message.
• Paraphrasing rephrases the patient’s message to ensure correct interpretation.

Communication Techniques

• Clarifying seeks to understand the patient's message by asking for more information or elaboration on a point.
• Focusing encourages the patient to select one topic as the primary focus of discussion.
• Reflecting assists the patient to reflect on feelings and thoughts.
• Stating Observations communicates observations of the patient back to them.
• Offering Information provides the patient with relevant data and asks for feedback to determine understanding.
• Summarizing concisely reviews main ideas from a discussion.
• Using Humor provides positive physiological and psychological effects on the body, but must be used appropriately.

Communication with Specific Patient Groups

• Ventilator-dependent patients may require alternative communication methods:
  • Communication board with alphabet, common phrases, and pictures.
• Aphasic patients have language function deficits due to brain injury.
  • Expressive aphasia: unable to send desired verbal message.
  • Receptive aphasia: unable to recognize or interpret incoming messages.
• Unresponsive patients: assume that all sound and verbal stimuli are heard.
  • Encourage providers, family, and friends to speak to unresponsive individuals.

Alternative Communication Methods

• Lip-reading: Patient mouths words for interpretation.
• Sign language: Hand and finger signals used for hearing-impaired patients.
• Paper and pencil/magic slate: Patient writes messages.
• Word or picture cards: Patient picks appropriate card or sorts cards into phrases.
• Magnetic boards with letters: Patient moves letters to spell words or phrases.
• Eye blinks: Predetermined system where blinks indicate yes or no answers.
• Computer-assisted communication: Patient uses keyboard for messages.
• Clock face communicator: Messages placed around a clock face.

Cultural Competence and Transcultural Nursing

• Culture: A set of learned values, beliefs, morals, social norms, and practices shared by a group, passed down through generations.
• Cultural competence: Awareness of one's own cultural beliefs and practices and their relation to others.
• Ethnocentrism: Belief that one's own culture is superior to others.
• Stereotypes: Generalized expectations about an individual or group.
• Transcultural nursing: Understanding and integration of different cultures into the patient plan of care.

Race and Ethnicity

• Race: Group of people who share biologic physical characteristics.
• Ethnicity: Group of people who share a common social and cultural heritage based on traditions, origin, practices, and physical characteristics.

Culturally Related Assessments

• Communication:
  • Language barriers must be identified and addressed.
  • Gestures and verbal expressions can have different meanings across cultures.
  • Professional translators are preferable to family or friends for accurate translations.
• Nonverbal Communication:
  • Meaning and acceptance of touch, eye contact, body language, and gestures vary greatly.
  • Respect patient's comfort levels with personal space.
• Space:
  • Cultures assign different comfort areas and meanings to personal space.
• Time:
  • Measurement of time and time orientation differ across cultures.
  • "Elasticity" of time may make managing chronic illness difficult.
• Social Organization:
  • Cultural behavior is influenced by social structures and family models.
  • Patriarchal structures often require men to make key decisions.
  • Matriarchal structures place women in charge of healthcare decisions.
  • Respect the patient's support system, within HIPAA guidelines.
• Religious Beliefs:
  • Religious beliefs and practices affect many aspects of healthcare.
• Health Practices:
  • Biomedical healthcare dominates in the United States.
  • Alternative therapies such as folk remedies, holistic treatments, and spiritual interventions are gaining traction.
  • Understand the relationship between different health systems and allow patients to follow practices that align with their cultural identity.

Biologic Variations

• Physical traits may be similar within a race or geographic region, but family history of diseases prevalent within those groups is important for healthcare.
• Cultural dietary practices can impact health.

Cultural Considerations in the Nursing Process

• Nursing diagnoses: Consider cultural implications of using diagnoses such as Insufficient Knowledge, Compromised Verbal Communication, Impaired Health Maintenance, or Noncooperation.
• Accommodations: Make necessary accommodations to the nursing process to meet the needs of patients from diverse backgrounds.

Family Dynamics

• Family: The basic unit of society, composed of individuals united by marriage, blood, adoption, emotional bonds, and social roles.
• Types of families:
  • Nuclear family: Traditional nuclear family (married man and woman with children) and modern redefined nuclear family (husband and wife with or without children).
  • Extended family: Includes grandparents, grandchildren, aunts, and uncles living in the same household.
• Inherent family functions: Protection, nurturance, education, sustenance, socialization (instilling morals, values), affection, acceptance, companionship, and growth.

Family Types

• Single-parent families can be formed due to choice or by circumstances like death, divorce, separation, or abandonment.
• The single parent assumes all responsibilities typically shared by two parents.
• Blended families (stepfamilies) arise when adults remarry and bring children from previous marriages.
• Potential stresses in blended families include fear of love or trust, loyalty conflicts between parents and stepparents, and jealousy among stepchildren.
• Social contract families involve a man and a woman living together with shared responsibilities, but without a legal commitment.
• Homosexual families consist of same-sex couples living together with shared responsibilities. Biological, adopted, and foster children may be part of this family structure.
• Transgender families include one or more parents who have undergone gender reassignment or are gender nonconforming. They share responsibilities and live together as a family unit.
• Adoptive families often resemble nuclear families with an adopted child. While the adoption process can be demanding, adoptive families achieve the same fulfillment as families with biological children.
• Grandfamilies are formed when children live with or are in the custody of grandparents. Common reasons for this include parental substance abuse, mental illness, military deployment, incarceration, and parental death.
• Children raised by grandparents or other family members have more stable and safer childhoods compared to placement with non-relatives.
• Foster families are formed when biological parents are unable or unwilling to provide safe care for their children.
• Foster care is often court-ordered due to abuse or neglect.
• Children remain in foster care until they "age out" into legal adulthood unless their biological parents regain stability and custody.

Family Patterns

• Family patterns describe the dynamics of relationships within the family.
• Autocratic families have unequal relationships with strict rules and expectations imposed by parents on children.
• Patriarchal families place the adult male as dominant in work, finances, and decision-making.
• Matriarchal families place the adult female as dominant in childcare, homemaking, and finances.
• Democratic families involve equal partnerships between adult members, promoting joint decision-making, compromise, and mutual support.

Qualities of Functional Families

• Commitment to the well-being of each family member.
• Appreciation and encouragement for achievements.
• Quality time spent with each individual member.
• A shared sense of purpose that promotes progress during challenging times.
• Harmony among family members.
• Effective communication.
• Established values, rules, and beliefs.
• Diverse coping mechanisms and resources to enhance family functioning.
• Effective problem-solving approaches.
• A positive outlook on life.
• Flexibility and adaptability in response to changes.

Family Development Stages

• Engagement/Commitment Stage: Couples acknowledge their intention to marry, receive support or opposition from friends and family, and make arrangements for the wedding, living situation, and future plans.
• Establishment Stage: Spans from the wedding until the birth of the first child. This stage marks the transition from independent individuals to a married, interdependent couple. Challenges include learning to live together, joint decision-making, communication, and integrating families. Success requires prioritizing commitment, shared goals, and respect.
• Expectant Stage: Begins with conception and continues through pregnancy. It necessitates adjustments to physiological and psychological changes, planning for childbirth, employment, childcare, and infant feeding. Surrogacy may be considered as an alternative to biological pregnancy.
• Parenthood Stage: Starts with the birth or adoption of the first child. This stage demands adaptability to limited free time, sleep, privacy, and intimacy. Parents often experience anxiety about their ability and competency as caregivers. Disengagement occurs when grown children leave home, necessitating a redefinition of parental roles.
• Senescence Stage: The final stage of the life cycle encompasses older adult years. Family remains a source of satisfaction and pleasure. Grandparents often balance independence with time spent around family, seeking closeness with grandchildren without assuming caretaking responsibilities. Women typically outlive their spouses due to longer life expectancy.

Causes of Family Stress

• Lifespan Variations: Stress triggers and manifestations differ across the lifespan. Infants may experience stress due to unmet needs. Toddlers often feel stressed during separation from their mothers. School-age children face pressure from school, parental expectations, and peer interactions. Common signs of stress in children include mood swings, acting out, eating or sleeping changes, physical symptoms, clinging to parents, and regression to earlier developmental stages.
• Chronic Illness: Financial resources, stability, and support determine a family's ability to cope with a member's chronic physical or mental illness.
• Working Mothers: Childcare arrangements are crucial when both parents work or in single-parent households. High-quality childcare provides a safe and healthy environment with age-appropriate education, open spaces, diverse activities, small class sizes, a suitable staff-to-child ratio, active staff engagement, and positive reinforcement.
• Abuse: Abuse encompasses physical, emotional, financial, verbal, and sexual abuse, as well as neglect. Children under one year old are most vulnerable and frequently abused by a parent.
• Risk factors for abuse include financial strain, social isolation, low self-esteem, history of abuse, strict and punitive parenting, immaturity, and lack of self-control. Early detection and prevention are crucial to stop abuse.
• Divorce: The impact of divorce on children varies and is often linked to their age at the time of separation. They may feel abandoned or unloved by both parents.
• Factors affecting the impact of divorce include the bitterness and conflict surrounding the divorce, the child's prior relationship with the separated parent, the effects of divorce on the custodial parent, and the post-divorce relationship between parents.
• Divorce leads to significant changes in the emotional environment, family roles, finances, lifestyle, and familiar surroundings.
• Parents are advised to encourage children to express their feelings, avoid using them as pawns, refrain from speaking negatively about the ex-spouse, seek professional help if needed, and reassure children that the divorce is not their fault.

Nursing Practice and Legalities

• LPN/LVN practice is guided by legal principles, laws, moral standards, and ethical principles.
• Nurses must understand legal standards and ethical principles to practice safely.
• Nurse Practice Acts govern the scope of nursing practice in each state.
• Ethical principles, shaped by society and culture, often set a higher standard than legal requirements.
• Legal standards and ethical principles protect the rights of individuals and support the healthcare system.

Overview of the Legal System

• The legal system comprises rules and regulations developed to meet societal needs.
• Laws define appropriate behavior, rewarding acceptable conduct and punishing unacceptable behavior.
• Nurses must understand the legal mandates and protections within the legal system.
• The law assigns fundamental legal duties and safeguards all members of the healthcare system.

Types of Law

• Criminal Law: Deals with offenses against the public.
  • Results in a verdict of guilty or innocent.
• Civil Law: Resolves disputes between individuals.
  • Determines accountability and innocence.
  • Monetary settlements are awarded based on liability.
• Statutory Law and Common Law: Developed by federal, state, and local governments in response to legal questions.
  • Often follows precedent (previous rulings on an issue).

Negligence

• Negligence refers to the absence of due care, often characterized by carelessness.
• Nurses and UAPs can be charged with negligence.
• Professional judgment and accountability are not necessary for establishing negligence.
• Negligence occurs when someone fails to act with the care and knowledge a prudent individual would.
  • Examples: medication errors, patient falls, use of restraints, equipment injuries.

Malpractice

• Malpractice signifies professional negligence.
• Four key elements must be present for a malpractice claim to be successful:
  • Duty: The established relationship between the patient and the nurse.
  • Breach of Duty: Failure to perform the duty in a reasonable and prudent manner.
  • Harm: This doesn't have to be physical injury; emotional distress can also be considered.
  • Proximate Cause: The breach of duty directly caused the harm.
• If malpractice is proven, the nurse can face legal penalties or restitution.
• Practicing within established rules, regulations, standards of care, and agency policies are critical to avoid malpractice charges.
• The nature of the nurse-patient relationship can influence a patient's decision to pursue legal action.

Levels of Responsibility

• Individuals can be held personally responsible for negligence or malpractice.
• Managers or supervisors may be held accountable for inadequate supervision or delegation.
• Employers can be found liable for employee actions if they fail to provide sufficient education, proper credentials, necessary supplies, or equipment.

Overview of the Legal Process

• Civil litigation: Legal disputes between individuals.
• Claim Filing: Begins when an individual believes a breach of duty has occurred, resulting in pain, suffering, or injury.
• Plaintiff: The complaining party seeks legal representation and files a formal complaint.
• Complaint: Names the defendant (person alleged to be responsible), outlines the facts of the case, defines legal issues, and specifies damages sought.
• Defendant: The accused individual is served a summons and usually hires an attorney. They provide a response, either admitting or denying the allegations.
• Verdict: The court renders a verdict based on evidence, testimony, witness credibility, and applicable laws.
• Appeals: Either party can appeal the verdict, seeking review by a higher court.
• Criminal Trial: Addresses crimes against the public, with the government bringing charges.
  • Attorneys present their cases.
  • Judge or jury deliberates on guilt or innocence.
  • A guilty verdict leads to a sentence (penalty) based on the severity of the crime, defendant's criminal history, and applicable laws.
• Appeals Process: A defendant convicted of a crime can appeal if there were errors in the process leading to the verdict or by the court proceedings.

Legal Relationships

• Legal liability for alleged harm can be held solely or shared by multiple parties.
• Patients or families can sue facilities, nursing personnel, medical staff, or ancillary departments.
• Nurses have autonomy in practice but face increasing liability.
• Accountability: Being responsible for one's own actions. It creates a legal duty and potential liability.
• Increased Litigation: Nurses face increased responsibilities in healthcare, including demands for greater knowledge and competence.
  • Staffing shortages, budgetary constraints, high patient acuity, and early discharge practices also contribute to increased litigation.
• Common Areas of Litigation: Standards of care, equipment use, documentation, and patient advocacy.
• Reasonable Prudent Nurse Standard: Nurse actions are compared to the hypothetical actions of a similarly educated and experienced nurse in similar circumstances.
• Nursing Orientation: Shouldn't be solely relied upon to make a nurse competent. Nurses must seek additional instruction and supervision when unfamiliar with tasks or procedures.

Nurse Practice Acts

• These laws define and limit the scope of nursing practice.
• All U.S. and Canadian states/provinces/territories have adopted nurse practice acts, with variations in specifics.
• Nurses must be familiar with the nurse practice act in their region.
• Employing institutions often impose practice limitations within the boundaries set by the state's nurse practice act.
  • They have the right to establish policies and procedures for nursing activities within those boundaries.
• Courts use various resources when determining if standards of care were met in specific situations.

Legal Issues

• Statutory and common law define patient and professional rights and responsibilities.
• Patients have a right to care consistent with established legal standards and principles, reflecting the nurse's obligation to act in their best interest.

Patient Rights

• Patients have expectations regarding healthcare services.
• Patient's Bill of Rights: Developed by the AHA to outline patient expectations, rights, and responsibilities.
  • Adapted by healthcare institutions to their environment.
  • Considers the cultural, religious, linguistic, and educational backgrounds of the population served.
• AHA's Goal: To promote public understanding of their rights and responsibilities as healthcare consumers.
• Nurse's Role: Failing to respect patient rights can breach the nurse-patient relationship.

The Joint Commission

• An independent accrediting agency for healthcare facilities in the US.

The Patient Self-Determination Act

• Regulates institutions receiving federal funding.
• Requires these institutions to have written policies on advance directives (like using life support if incapacitated), the right to accept or refuse treatment, and being fully involved in healthcare decisions.

Health Insurance Portability and Accountability Act (HIPAA)

• Healthcare providers who maintain and transmit health information must implement safeguards for patient privacy.
• Establishes rules and limits on accessing patient health information.
• Penalties are assigned for inappropriate disclosure of protected health information.
• All healthcare providers must be knowledgeable about HIPAA standards and protect patient privacy.

Healthcare Institutions (Obligations)

• Healthcare institutions must uphold patient rights, including:
  • Access to care without prejudice.
  • Treatment with respect and dignity.
  • Privacy and confidentiality.
  • Personal safety.
  • Full information about their condition and treatment.

Patient Responsibilities

• Patients' responsibilities to healthcare institutions include:
  • Providing accurate information about themselves.
  • Disclosing known health conditions.
  • Participating in treatment and care decisions.

Informed Consent

• The Patient Care Partnership establishes the patient's right to healthcare decisions.
• Definition: Full disclosure of information needed for the patient to make an informed decision before any invasive procedure or treatment.
• The patient has the right to accept or reject proposed care after understanding its potential benefits, risks, alternatives, and consequences of refusal.
• Failure to obtain informed consent can result in civil liability for battery (unlawful touching, intent to harm not necessary).
• Patients can withdraw or limit consent at any time.
• Consent can be implied by a patient's actions or verbalized acceptance of treatment.
• Written Consent Forms: Often required for invasive procedures.
• Appropriate Consent Provider: Must be at least 18 years old, unless they are:
  • Married.
  • Court-approved emancipated.
  • Living independently from parents/guardians for 60 days and financially independent.
  • Serving in the armed forces.

Competence

• The patient must be mentally competent to provide consent.
• Consent cannot be obtained from someone impaired by alcohol, drugs, or mentally unfit.
• If a patient is deemed incompetent, a legal process is in place to determine who can provide consent.
• Provider's Responsibility: The physician or nurse practitioner performing the procedure provides necessary information to the patient.
• Nurse's Role: Witnesses the patient's signature on the consent form, but does not provide information about the procedure or treatment.

Confidentiality

• Nurses have a duty to protect patient information, regardless of how it is stored.
• Access should be on a "need-to-know" basis.
• Breach of confidentiality risks legal liability, civil/criminal charges, and termination.
• Confidentiality applies beyond the work shift.
• Securing materials containing confidential information is the nurse's responsibility.
• Computer logins should be logged out properly to prevent unauthorized access.
• Written notes and chart forms must be stored in secure locations.
• Protected Health Information (PHI): Identifiable patient information, extending beyond name and including admission/discharge dates, social security number, photographs, addresses, phone numbers, date of birth, and age 89 or older.
• Discussions about patients and personal information should be held in private rooms.

Social Media

• Social media encompasses online and mobile tools for sharing information, opinions, experiences, and media.
• Healthcare facilities often have policies regarding smartphone and handheld devices in patient care areas.
• Benefits of social media: Educational materials, professional advancements, nurse networking, mentoring, access to resources.
• Violations:
  • Blurring boundaries between nurses and patients.
  • Taking photos or sharing information about patients, families, or the facility.
  • Disparaging comments about the care facility.
• Consequences: Discipline up to termination, nursing license sanctions, or other penalties.

Medical Records

• Laws regulate the collection, maintenance, and disclosure of medical record information.
• Each healthcare institution has policies and procedures for patient records.
• Medical records are not public documents and must be kept secure.
• Confidentiality breaches can result in legal liability.
• In a lawsuit, both parties can use medical records to present arguments.
  • Records document whether standards of care were met. ### Patient Confidentiality and Privacy
• Employing institution policies regarding patient medical records must be followed.
• All entries in the medical record must be permanent, accurate, complete, and legible.
• Invasion of privacy involves the right to be left alone and remain anonymous.
• Consent for treatment does not waive the right to privacy.
• Privacy concerns include physical exposure or disclosure of patient information; examples include closing the door or curtain during patient care and keeping report sheets confidential.

Reporting Abuse

• Health care professionals are legally required to report certain information to the appropriate authorities.
• Reports should be given to a supervisor or directly to the police, following agency policy.
• Health care professionals are protected from liability when acting in good faith to report mandated information.
• The Child Abuse Prevention Treatment Act mandates the reporting of child abuse. Health care professionals are mandated reporters.
• Failing to report suspected cases of child abuse can result in fines or imprisonment.
• Withholding medical treatment of an infant born with serious life-threatening handicaps is a form of child abuse.
• Institutions receiving federal funds are legally responsible for investigating the withholding of medical treatment to an infant.
• Withholding lifesaving treatment and care is a form of passive euthanasia (letting a person die) and medical neglect.
• Populations at increased risk for spousal and elder abuse include women and older adults.
• Fines, restraining orders, and imprisonment are used to protect victims of abuse.
• Abuse is an underreported crime.
• Nurses are responsible for knowing the signs of abuse and the procedures for reporting suspected cases.
• Workplace violence includes verbal abuse, emotional abuse, sexual harassment, physical assault, and threatening behavior.

Avoiding Lawsuits

• Providing compassionate and competent nursing care is the best defense against a lawsuit.
• The nurse-patient relationship should be based on trust and respect.
• Open and honest communication is key to building a therapeutic relationship and can resolve patient dissatisfaction before legal action is taken.
• Following standards of care, facility policies and procedures, and the scope of practice for the LPN/LVN reduce the likelihood of a lawsuit.
• Staying current on practice developments and continuing education ensures competence.
• Nurses are not required to assist victims when acting as a “private citizen”.
• Liability may be limited under Good Samaritan laws if the nurse chooses to offer help.
• The Good Samaritan law encourages assistance in emergencies outside of a medical facility.
• State and provincial laws regarding Good Samaritan laws vary.
• Proper documentation in the medical record is crucial in assessing liability.
• “Care was not given if it was not charted.”
• Omissions in charting can negatively impact legal cases.

Disciplinary Process

• Seek legal representation if you receive a letter from the board of nursing alleging breaches of standards of care or infractions of patient safety practices.
• Licensure issues fall under administrative law.
• Potential sanctions against a nursing license include:
  • Dismissed charge
  • Investigation agreement
  • Letter of reprimand
  • Probation with stipulations
  • Mandated diversion program
  • Suspension with stipulations
  • Revocation of license

Ethics

• Ethics is the study of the relationship between moral actions, values, and their impact on society.
• Ethics refer to values that influence a person’s behavior and their beliefs about what is right or wrong.
• Nursing ethics involve moral values and principles that influence personal and professional conduct.
• Nursing ethics propose the duties and obligations of nurses to their patients, other health care professionals, the profession, and society.

Advance Directives

• Advance directives are signed and witnessed documents that provide specific instructions for health care treatment if a person is unable to make these decisions personally.
• The two basic types are living wills and durable powers of attorney for health care.
• It's important to understand patients’ cultural beliefs and values when explaining advance directives.
• The patient’s record should document whether or not they have signed an advance directive.
• Hospitals are required to follow state law regarding advance directives and provide education for staff and the public.
• For either type of advance directive to be enforceable, the patient must be legally incompetent or lack capacity to make decisions regarding health care treatment.
• A living will directs treatment according to the patient’s wishes in the event of a terminal illness or condition.
• If a health care worker follows the directions of a living will, they are immune from liability.
• A durable power of attorney designates an agent, surrogate, or proxy to make health care decisions for a patient based on their wishes.
• Autonomy gives the patient the right to refuse medical treatment.

Development of Ethical Principles

• Values are personal beliefs about the worth of an object, idea, custom, or attitude.
• Values vary among people and cultures and are influenced by experience, observation, and reasoning.
• Societies influence children’s behaviors and values.
• Value clarification involves reflecting on and assessing one’s own values.
• Nurses can assist patients with value clarification by encouraging them to express feelings and thoughts related to a situation without contributing personal opinions.
• Ethical dilemmas are complex situations without a clear right or wrong answer.
• The first step in addressing an ethical dilemma is identifying it as an ethical issue.
• Many situations present a combination of legal and ethical questions.
• A complete assessment of the situation should be conducted with as much information as possible gathered.
• Ethical principles provide a framework for decision making.

Ethical Principles in Nursing Practice

• Respect for people, autonomy, beneficence, nonmaleficence, and justice are common ethical principles.
• Respect for people views all human life as sacred with each individual having inherent worth.
• Autonomy refers to freedom of personal choice and the right to be independent and make decisions freely.
• Beneficence means doing good or acting for someone’s good.
• Nonmaleficence means to do no harm.
• Justice is the concept of what is fair.
• Balancing conflicting ethical principles is a challenge for nurses.

Code of Ethics

• Professional organizations have developed codes of ethics for the nursing profession to regulate actions and provide guidelines for ethical behavior.
• Codes of ethics aim to help health care practitioners become more competent, trustworthy, and accountable.
• LPN/LVNs must
  • know and function within the scope of practice.
  • maintain patient confidences.
  • provide health care without discrimination.
  • maintain a high degree of professional and personal behavior.
  • take an active role in the development of the LPN/LVN profession.

Reporting Unethical Behavior

• Nurses have a duty to report behavior that does not meet established standards.
• Unethical behavior includes failing to perform the duties of a competent, caring nurse.
• When considering reporting unethical behavior, determine if the behavior or practice:
  • puts the patient or facility at risk.
  • demonstrates incompetence.
  • involves the use of alcohol or drugs.
  • is related to a physical or mental condition.
  • violates a nursing statute.
• Follow the proper chain of command when reporting unethical behavior.

Ethical Issues in Health Care

• There is no absolutely right or wrong answer to ethical issues.
• Ethical issues change as society changes.
• Practitioner-assisted suicide (PAS) is also known as active euthanasia.
• Each state has the ability to legalize or ban assisted suicide.
• PAS is not consistent with the philosophy of nursing, as it violates the principle of nonmaleficence and beneficence.
• PAS supporters cite the ethical principles of autonomy and the right to self-determination.
• Competent adults have the right to refuse treatment.
• To exercise the right to refuse treatment, patients may prepare advance directives such as living wills and health care proxies.
• Living wills specify acceptable and unacceptable lifesaving treatments.
• A health care proxy makes decisions regarding medication treatment if the patient becomes unable to make them.
• Nurses must be aware of state laws regarding advance directives.
• Do-Not-Resuscitate orders (DNR) are written in the medical record by a physician after consulting with the patient’s family.
• The nurse has the duty to follow a DNR order once it is in the patient chart.
• Refusal to treat arises when a patient’s care requires a nurse to do something that conflicts with their personal moral beliefs.
• Nurses must communicate any strong moral or religious beliefs regarding a patient’s treatment.
• Nurses should not abandon a patient but can request another assignment.

Patient Records and Documentation

• The patient chart (health record) is a legal record used to meet various demands of the health, accreditation, medical insurance, and legal systems.
• Charting, recording, or documenting involves recording interventions carried out to meet the patient’s needs.
• Interventions should include the type of intervention, time care was rendered, and the signature and title of the person providing care.
• Good documentation reflects the nursing process and is necessary for the evaluation of patient care for reimbursement.
• Most facilities use an electronic health record (EHR) or electronic medical record (EMR).
• Nurses must understand medical records and documentation guidelines.
• Patient health records provide a concise, accurate, and permanent record of medical and nursing problems, plans of care, care given, and patient responses to treatments.
• Patient health records facilitate accurate communication and continuity of care.
• Proper documentation covers all areas of patient needs: physical, emotional, psychological, social, and spiritual.
• Patient records are audited to assess the quality of patient care.
• Insurance companies review the patient record to determine if necessary care was given.
• The patient health record is a legal document and can be used in court.
• Detailed documentation is important for legal protection.

Electronic Health Record (EHR)

• The EHR includes information for management of admissions, billing, and the communication of orders for diet, pharmacy, and diagnostic tests.
• The EHR allows all health care providers to view a patient’s record for increased continuity of care.
• EHRs are efficient because documented information can be automatically transferred to other areas.
• EHRs include options for individualized care plans, acuity levels, medication administration records (MARs).
• EHRs allow exchange of patient data within multiple facilities.
• EMRs exchange patient data within one facility.
• Documenting at the bedside saves time and allows current information to be immediately available to all who need it.

SBAR (situation, background, assessment, and recommendation)

• SBAR is a method of communication among health care workers and a part of documentation.
• SBAR is a safety measure in preventing errors from poor communication.

Basic Guidelines for Documentation

• Accurate documentation is crucial for successful communication.
• Document all nursing interventions, assessments, and patient responses.
• Maintain confidentiality and accuracy in all documentation.

Documentation

• Accurate documentation protects nurses in legal claims
• Nurses are responsible for documenting all assessments, interventions, patient responses, instructions, and referrals
• All patient care must be documented
• Nursing care not documented is considered not given
• Inappropriate documentation (e.g. documenting care in advance, documenting incorrect data) may lead to nursing malpractice
• Incident reports (e.g. unplanned occurrences) are filled out for any unusual event
• Report only objective information, avoiding unnecessary details
• Include the care provided in response to the incident and the name of the health care provider notified
• Do not include the incident report in the patient’s medical record or nurses’ notes
• Clinical pathways help to provide standardized, integrated care plans
• Clinical pathways replace other nursing forms, such as the care plan

Communication

• Communication is the exchange of information
• Communication can be verbal and nonverbal
• Effective communication minimizes miscommunication
• The message intended is not always the message received
• Two-way communication allows for exchange between the nurse and the patient, and its purpose is to meet the needs of the nurse and the patient and to establish a trusting relationship.
• Nurses should communicate with patients in ways they understand by using common language rather than medical terminology
• Tone of voice can be influenced by emotions, the situation, confidence, and geographic and cultural influences
• Extended eye contact can be interpreted as aggression or arouse anxiety
• Cultural considerations influence how people interpret eye contact
• Professional appearance conveys self-respect and competence
• Assertive Communication: Confidently and comfortably expressing thoughts and feelings while respecting the legitimate rights of the patient
• Aggressive Communication: Non-therapeutic communication that is destructive and overpowering
• Unassertive Communication: More open, yet no one really benefits from the interaction
• Therapeutic nurse-patient relationships are based on caring, sincerity, empathy, and trustworthiness
• Trust is essential for an effective nurse-patient interaction
• The nurse is obligated to report a patient’s statement of intent to do self-harm or to harm others
• Therapeutic communication facilitates the formation of a positive nurse-patient relationship and actively involves the patient in all areas of care
• Nontherapeutic communication blocks the development of a trusting and therapeutic relationship

Therapeutic Communication Techniques

• Therapeutic communication requires the nurse to be aware of the patient’s feelings and the ability to respond to the patients needs through the use of verbal and nonverbal communication skills.
• Listening is an effective method of therapeutic communication
• Active listening requires full attention to what the patient is saying
• Passive listening lets the patient know the nurse is interested and being attentive to what is being said
• Silence allows the participants to organize their thoughts
• Touch is a form of nonverbal communication that is inherent in the practice of nursing
• Touch must be used with discretion and sensitivity to sociocultural norms
• Conveying Acceptance – Patients are sometimes reluctant to give the nurse complete information, especially if it relates to values, beliefs, lifestyles and practices
• The nurse’s acceptance and willingness to listen and respond to what a patient is saying without passing judgment on the patient is key to the development of a therapeutic nurse-patient relationship.
• Minimal encouragement communicates to the patient that the nurse is interested and wants to hear more.
• Closed questioning is focused and seeks a particular answer; usually requires and elicits only a “yes” or “no” or one-word to two-word answer.
• Open-ended questioning does not require a specific answer and cannot be answered by “yes,” “no,” or a one-word response.
• Restating is a technique where the nurse repeats to the patient what is believed to be the main point that the patient is trying to convey.
• Paraphrasing is where the nurse restates the patient’s message in the nurse’s own words.

Communication Techniques

• Clarifying encourages the patient to elaborate, verifying the message received is accurate
• Focusing helps the nurse gather specific information when the patient's message is too vague
• Reflecting assists the patient to reflect on thoughts and feelings
• Stating observations allows for clarification of intended message when verbal and nonverbal cues don't match
• Offering information provides relevant data to the patient and checks their understanding
• Summarizing concisely reviews main ideas from a discussion
• Using humor can be therapeutic but is not always appropriate

Communication with Special Needs Patients

• Ventilator-dependent patients often use communication boards
• Aphasic patients struggle with language function due to brain injury
  • Expressive aphasia: inability to send verbal messages
  • Receptive aphasia: inability to recognize or interpret verbal messages
• Unresponsive patients: encourage family and friends to communicate

Alternative Communication Methods

• Lip-reading: patient mouths words
• Sign language: using hand signals
• Paper and pencil: patient writes messages
• Word or picture cards: patient selects appropriate cards
• Magnetic boards: patient moves letters to spell words
• Eye blinks: predetermined yes/no system
• Computer-assisted communication: typing messages
• Clock face communicator: messages placed around a clock

Culture and Diversity

• The United States comprises diverse cultures, each with unique languages, values, beliefs, health practices, communication styles, and religions
• Culture: shared learned values, beliefs, morals, social norms, and practices passed down through generations
  • Subcultures: share characteristics with the primary culture but have distinct patterns of behavior and ideals
  • Individual differences exist within each group based on factors such as age, generation, dialect, gender, geographic location, religion, and socioeconomic background
• Cultural Competence: awareness of one's own cultural beliefs and practices in relation to others
  • Ethnocentrism: believing that one's own culture is superior
  • Stereotypes: generalized expectations about behaviors or groups
• Transcultural Nursing: understanding and integrating different cultures into patient care

Race and Ethnicity

• Race: group of people sharing biological physical characteristics
• Ethnicity: group of people sharing common cultural heritage based on traditions, national origin, social practices, and physical characteristics

Culturally Related Assessments

• Communication: be mindful of language barriers and nonverbal communication
  • Language barriers: use a professional translator
  • Nonverbal communication: variations in touch, eye contact, and gestures
• Space: respect each patient's personal space
• Time: different cultural interpretations of time and scheduling
• Social Organization: understanding family structures
• Religious Beliefs: awareness of practices that affect health care
• Health Practices: understanding different health systems:
  • Biomedical: focuses on physical and chemical interventions
  • Folk: incorporates religion and nature
  • Holistic: emphasizes balance in the physical, social, and metaphysical worlds
  • Alternative: nonmedical forms of therapy

Cultural Considerations in the Nursing Process

• Nursing diagnoses: consider cultural limitations
• Patient behavior: evaluate from the individual's cultural perspective
• Accommodations: adapt nursing care to cultural needs

Family Dynamics

• Family: the basic unit of society, defined by connections through marriage, blood, adoption, emotional bonds, and social roles
• Types of Families:
  • Nuclear family: husband and wife with or without children, living independently
  • Extended family: traditional nuclear family with additional members living together

Single-Parent Family

• Can be formed due to choice, death, divorce, separation, or abandonment.
• The single parent takes on responsibilities typically shared by two individuals.

Blended (Reconstituted Family)

• Also known as a stepfamily, formed when adults remarry and combine children from prior marriages.
• Presents potential stressors including fear of love and trust, loyalty conflicts, and jealousy.

Social Contract Family/Cohabitation

• Consists of a couple living together with shared responsibilities but without legal commitment.

Homosexual Family

• Involves same-sex couples sharing responsibilities, possibly with biological, adopted, or foster children.

Transgender Family

• May include one or more parents who have transitioned or are gender non-conforming, sharing responsibilities.

Adoptive Family

• Typically resembles a nuclear family with an adopted child.
• Adoption can be time-consuming, stressful, and expensive, but often brings fulfillment similar to biological families.

Grandfamilies

• Children live with or are in the custody of grandparents.
• Often due to parental substance abuse, mental illness, military deployment, incarceration, or death.
• Research suggests that children in grandfamilies experience more stable and safe childhoods than when placed with non-relatives.

Foster Family

• Biologic parents are unable or unwilling to provide adequate care for their children.
• Usually court-ordered due to abuse or neglect.
• Parents may be given time to stabilize and regain custody, otherwise, children remain in foster care until legal adulthood.

Family Patterns

• Describe how family members interact with one another.
• Autocratic: Unequal relationships with strict parental control.
• Patriarchal: Adult male holds dominant roles in finances, work, and decision-making.
• Matriarchal: Adult female takes the lead in childcare, homemaking, and finances.
• Democratic: Adults function as equals, engaging in joint decision-making, compromise, support, and growth.

Qualities of Functional Families

• Commitment to family members' well-being.
• Appreciation and encouragement for accomplishments.
• Quality time spent with individual members.
• Sense of purpose that encourages progress during difficult times.
• Harmony and effective communication between members.
• Established values, rules, and beliefs.
• Variety of coping mechanisms and resources.
• Effective problem-solving methods.
• Positive outlook.
• Flexibility and adaptability.

Stages of Family Development

• Engagement or Commitment Stage: Couple acknowledges marriage consideration.
• Establishment Stage: Transition from single to married life, lasting until the birth of the first child.
• Expectant Stage: Begins with conception and includes pregnancy.
• Parenthood Stage: Starts with the birth or adoption of the first child.
• Senescence Stage: Last stage, encompassing older adult years.

Causes of Family Stress

• Early Childhood: Needs unmet in infancy, separation from mothers in toddlers.
• School-age Children: School pressures, parental expectations, social interactions.
• Chronic Illness: Financial strain, lack of support, and stability can hinder family coping.
• Working Mothers: Requires childcare arrangements when both parents work or in single-parent situations.
• Abuse: Physical, emotional, financial, verbal, sexual abuse, and neglect.
• Divorce: Impacts children's emotional well-being, often depending on their age at separation.

Divorce and Children

• Children may feel abandoned or unloved.
• Reconciliation fantasies persist even after divorce.
• Factors influencing impact include: bitterness, prior relationship with the separated parent, effect on custodial parent, and the parent's post-divorce relationship.
• Divorce creates major changes in family roles, finances, lifestyle, and surroundings.
• Parents are advised to: Encourage open communication, avoid using children as pawns, refrain from negativity about the ex-spouse, seek professional help if needed, and reassure children that the divorce is not their fault.

LPN/LVN Nursing Practice

• Guided by a combination of legal principles, established laws, moral standards, and ethical principles.
• Nurse practice acts are state laws that govern the scope and practice of nursing.
• Laws establish minimum standards of care, while ethical principles often impose higher duties.

Overview of the Legal System

• The law prescribes proper behavior and defines acceptable limits.
• Nurses must have a basic understanding of the legal system to protect themselves and patients.
• Legal duties and protections are defined by the law for all members of the healthcare system.

Types of Law

• Criminal Law: Deals with crimes against the public, resulting in verdicts of guilty or innocent.
• Civil Law: Involves disputes between individuals, with outcomes determined by accountability or innocence.
• Statutory Law and Common Law: Developed by federal, state, and local governments to address legal questions and often follow precedent (past rulings).

Negligence

• Refers to the absence of due care.
• Applies to nurses and unlicensed assistive personnel (UAP).
• Examples include medication errors, patient falls, restraints, equipment injuries, and failure to act with reasonable care.

Malpractice

• Refers to professional negligence and involves four key elements:
  • Duty: Established relationship between patient and nurse.
  • Breach of duty: Failure to perform duty in a reasonable manner.
  • Harm: Any kind of harm, not just physical injury.
  • Proximate Cause: The breach of duty directly caused the harm.
• Nurses can be held legally accountable for malpractice.
• Key to avoiding malpractice charges is to practice within rules, standards of care, and facility policies.

Legal Process

• Civil Litigation: Legal disputes between individuals; most healthcare lawsuits fall under this category.
• Plaintiff: The party bringing the lawsuit.
• Defendant: The party accused of wrongdoing.
• Verdict: The court's decision based on evidence, testimony, witness credibility, and relevant laws.
• Appeals: A process for reviewing a court verdict.
• Criminal Trials: Involve crimes against society, with the outcome determining guilt or innocence.
• Sentencing: Penalties imposed on defendants found guilty.

Legal Relationships

• Liability for harm can be held solely by individuals or shared between multiple parties, including facilities, nurses, medical staff, or ancillary departments.
• Nurses have autonomy in practice but can also be held legally accountable for their actions.
• Increased responsibilities, technological advancements, staffing shortages, and budgetary constraints contribute to rising litigation against nurses.

Nurse-Patient Relationship

• Begins when a nurse accepts a patient care assignment.
• Establishes a legal duty to provide professional care.
• Creates a legal and ethical obligation for nurses to advocate for their patients' interests.

Regulation of Practice

• Standards of Care: Define expected, permitted, and prohibited actions within nursing practice.
• Derived from federal and state laws, rules, and regulations.
• Regularly evaluated and revised by professional organizations like the American Nurses Association (ANA).
• Scope of Practice: Defines the boundaries of nursing practice.
• Nursing Liability: May arise from practice, monitoring, and communication failures.
• Nurse Practice Acts: Define and formally limit the scope of nursing practice.
• Each state, province, or territory has its own nurse practice act.

Legal Issues

• Statutory and Common Law: Help define patient and nursing professional rights and responsibilities.
• Patients' Rights: Outlined by the American Hospital Association (AHA) and include:
  • Access to healthcare without prejudice.
  • Treatment with respect and dignity.
  • Privacy and confidentiality.
  • Personal safety.
  • Comprehensive information about their condition and treatment.
• Joint Commission: Independent accrediting agency for healthcare facilities in the United States.
• Patient Self-Determination Act: Requires institutions receiving federal funding to have policies on advance directives, the right to refuse treatment, and participation in healthcare decisions.
• Health Insurance Portability and Accountability Act (HIPAA): Protects patient health information and sets limits on who can access it.
• Health Care Institutions' Obligations: Must uphold patient rights related to healthcare access, respect, privacy, safety, and information disclosure.
• Patient Responsibilities: Include:
  • Providing accurate information.
  • Disclosing known conditions.
  • Participating in treatment and care decisions.

Informed Consent

• Established by The Patient Care Partnership.
• Involves full disclosure of information necessary for patients to make informed decisions about invasive treatments or procedures.
• Patients have the right to accept or reject treatment after understanding benefits, risks, alternatives, and consequences of refusal.
• Failure to obtain informed consent can lead to civil liability for battery.
• Patients can withdraw or limit consent at any time.
• Consent can be implied by actions or verbal statements.
• Written consent is typically required for invasive procedures.
• Consent from individuals under 18 years of age is governed by specific criteria, including marriage, court-approved emancipation, living independently, or service in the armed forces.
• Competence: Patients must be of sound mind to provide consent.
• Impaired or Impaired Consent: Consent cannot be given by individuals under the influence of alcohol or drugs. Legal processes exist to determine who can consent on behalf of incompetent individuals.

Confidentiality

• Nurses have a duty to protect patient information, accessing it only on a need-to-know basis.
• Breaches of confidentiality can lead to legal liability, civil or criminal action, termination of employment, and disciplinary actions against the nursing license.
• Confidentiality extends beyond the work shift and includes securing materials containing confidential information.
• Accessing computerized records requires appropriate logout procedures.
• Written notes and chart forms must be stored in restricted areas.
• Protected Health Information (PHI): Includes identifiers such as name, admission/discharge dates, social security number, photos addresses, phone numbers, date of birth, and age for patients 89 years or older.
• Conversations regarding patient information should occur in private settings, avoiding public spaces.

Social Media

• Social media presents ethical and legal challenges for nurses.
• Access can be valuable for education, professional connections, and mentorship.
• Health care facilities have policies regarding social media use.
• Violations typically involve blurring boundaries with patients, sharing patient information, or making disparaging remarks about the facility.
• Consequences for violations can include disciplinary action, termination, and nursing board sanctions.

Medical Records

• Laws and facility policies govern the collection, maintenance, and disclosure of medical records.
• Medical records are not public documents and must be kept secure.
• Breaches of confidentiality related to medical records can result in legal liability.
• Medical records can be used in legal proceedings to present evidence.

Patient Medical Records

• Employing institutions' policies and procedures regarding patient medical records must be followed.
• All entries in the medical record must be permanent, accurate, complete, and legible.
• Invasion of privacy involves the right to be left alone and remain anonymous.
• Consent for treatment does not waive the right to privacy.
• Privacy concerns may include physical exposure or disclosure of patient information to others.

Reporting Abuse

• Healthcare professionals are mandated to report certain information to appropriate authorities.
• Reports should be given to a supervisor or directly to the police, adhering to agency policy.
• Healthcare professionals are protected from liability when acting in good faith to report mandated information.
• The Child Abuse Prevention Treatment Act made reporting child abuse mandatory.
• Failure to report suspected child abuse can result in fines or imprisonment.
• Withholding medical treatment from infants with life-threatening handicaps is considered child abuse.
• Withholding lifesaving treatment is a form of passive euthanasia and medical neglect.
• Populations at increased risk for spousal and elder abuse include women and older adults.
• Abuse is an underreported crime.
• Nurses must know signs of abuse and reporting procedures.

Workplace Violence

• Workplace violence includes verbal abuse, emotional abuse, sexual harassment, physical assault, and threatening behavior.

Avoiding Lawsuits

• The best defense against a lawsuit is to provide compassionate and competent nursing care.
• The nurse-patient relationship should be based on trust and respect.
• Open and honest communication is crucial for building a therapeutic relationship and resolving patient dissatisfaction.
• Adhering to standards of care, facility policies and procedures, and the LPN/LVN scope of practice reduces the likelihood of lawsuits.
• Staying current on practice developments and engaging in continuing education ensures competence.
• Nurses are not obligated to aid victims when acting as private citizens.
• Good Samaritan laws offer limited liability protection when offering assistance in emergencies outside of a medical facility.
• Proper documentation in the medical record is essential for liability assessment.
• "Care was not given if it was not charted."

Disciplinary Process

• Seek legal representation if receiving a letter from the board of nursing alleging breaches of standards of care or patient safety practices.
• Licensure issues fall under administrative law.
• Potential sanctions for licensure issues or disciplinary actions include:
  • Dismissed charge
  • Investigation agreement
  • Letter of reprimand
  • Probation with stipulations
  • Mandated diversion program
  • Suspension with stipulations
  • Revocation of license

Ethics

• Ethics studies the relationships between moral actions, values, and their societal impact.
• Nursing ethics involve moral values and principles that affect personal and professional conduct.
• Nursing ethics define the duties and obligations of nurses to patients, other professionals, the profession, and society.

Advance Directives

• Advance directives are signed and witnessed documents providing instructions for healthcare treatment when the patient is unable to make decisions.
• The two basic types are living wills and durable powers of attorney for healthcare.
• Understanding patients' cultural beliefs and values is crucial when explaining advance directives.
• Whether a patient has signed an advance directive must be documented in the patient's record.
• For advance directives to be enforceable, the patient must be legally incompetent or lack decision-making capacity regarding healthcare treatment.
• A living will provides written directions for treatment during terminal illness or conditions.
• A durable power of attorney for healthcare designates an agent to make healthcare decisions on the patient's behalf.
• Autonomy gives the patient the right to refuse medical treatment.

Ethical Principles

• Values are personal beliefs about the worth of objects, ideas, customs, or attitudes.
• Value systems are individual and govern what is deemed right or wrong.
• Values influence everyday decisions and are learned through experience, observation, and reasoning.
• Value clarification involves reflecting on and assessing one's own values.
• Ethical dilemmas are situations without clear right or wrong answers.
• The first step in addressing an ethical dilemma is identifying it as an ethical problem, not resolvable by applying external laws, rules, policies, or procedures.
• Ethical principles provide a framework for decision-making in ethical dilemmas.

Ethical Principles in Nursing Practice

• The most fundamental ethical principle is respect for people, viewing all human life as sacred with inherent worth.
• Autonomy refers to freedom of personal choice and the right to make decisions independently.
• Beneficence means doing good or acting for someone's good.
• Nonmaleficence means to do no harm.
• Justice refers to fairness, ensuring all patients have equal rights to nursing interventions.

Code of Ethics

• Professional organizations develop codes of ethics to regulate actions and provide guidelines for ethical behavior.
• Codes of ethics aim to enhance the competence, trustworthiness, and accountability of healthcare professionals.
• LPN/LVN code of ethics includes:
  • Functioning within the scope of practice
  • Maintaining patient confidences
  • Providing care without discrimination
  • Maintaining professional and personal conduct
  • Active participation in LPN/LVN profession development

Reporting Unethical Behavior

• Nurses have a duty to report unethical behavior that does not meet established standards.
• Unethical behavior includes failing to perform the duties of a competent and caring nurse.
• When reporting unethical behavior, consider if it puts the patient or facility at risk, demonstrates incompetence, involves alcohol or drug use, is related to a physical or mental condition, or violates a nursing statute.
• Follow the proper chain of command when reporting unethical behavior, explaining facts clearly without personal opinions.
• The nurse's primary duty is to the patient's health, safety, and well-being.

Ethical Issues in Healthcare

• Ethical issues are influenced by societal changes.
• Practitioner-assisted suicide is also known as active euthanasia, where the healthcare provider actively ends a patient's life.
• Each state has the authority to legalize or ban assisted suicide.
• Practitioner-assisted suicide is not consistent with nursing philosophy or ethics due to nonmaleficence (do no harm) and beneficence (duty to protect life).
• PAS violates the Code of Ethics for Nurses and the profession's ethical tradition.
• PAS supporters argue for autonomy and self-determination.
• Competent adults have the right to refuse treatment.

Do-Not-Resuscitate Orders

• DNR orders are written in the medical record when the patient is incapacitated and there is little hope for recovery.
• The nurse has a duty to follow a DNR order once it is documented in the patient chart.

Refusal to Treat

• Refusal to treat arises when a patient's care requires a nurse to act against their personal moral beliefs.
• Do not abandon the patient; ask for another assignment if moral beliefs conflict with care decisions.
• The nurse has a duty to uphold the ethical principle of respect for all people without discrimination.

Patient Records

• The legal record used to meet the demands of health, accreditation, medical insurance, and legal systems is called the patient chart or health record.
• Documentation in the patient chart is referred to as charting, recording, or documenting.
• Documenting involves recording interventions carried out to meet patient needs, including:
  • Type of intervention
  • Time care was rendered
  • Signature and title of the person providing care
• Good documentation reflects the nursing process and is necessary for patient care evaluation and reimbursement.
• Most facilities use an electronic health record (EHR) or electronic medical record (EMR).
• Nurses must be proficient in using medical records effectively and efficiently.
• Patient records serve five basic purposes:
  • Documented communication
  • Permanent record for accountability
  • Legal record of care
  • Teaching
  • Research and data collection
• Patient health records provide a concise record of medical and nursing problems, care plans, care given, and patient responses.
• Proper documentation covers all areas of patient needs and concerns.
• Patient records are audited to assess the quality of patient care.
• Insurance companies review patient records, including nursing notes, to determine if necessary care is being given or has been given.
• The patient health record is a legal document and can be used in court proceedings; detailed documentation protects those involved in patient care.

Electronic Health Record

• EHR includes nursing care, information for admissions, billing, and communication of orders.
• EHR allows the exchange of patient data within and between facilities, encouraging continuity of care.
• EHR systems are more efficient because documented information can be automatically transferred.
• Nursing documentation options include individualized care plans, acuity levels, and medication administration records (MARs).
• EHR and EMR are not the same.
  • EHR exchanges patient data within and between facilities.
  • EMR exchanges patient data within one facility.
• Documenting at the bedside saves time and makes current information immediately available to all healthcare providers.

SBAR

• SBAR is a communication method used among healthcare workers and a part of documentation.
• SBAR (situation, background, assessment, and recommendation) is a safety measure to prevent errors from poor communication.

Basic Guidelines for Documentation

• Accurate documentation directly impacts communication success.
• Include patient observations, interventions provided, and patient responses.
• Charting must be objective, legible, and accurate, avoiding opinions and subjective statements.
• Chart promptly and comprehensively; do not rely on memory.
• Use proper grammar and spelling.
• Follow facility-specific charting policies.
• Document all patient care, interventions, and significant events.
• Document the patient's refusal of care or treatment.
• Correct charting errors with a single line through the error, initialing and dating the correction.
• Avoid blank spaces, leaving no room for additions or alterations.
• Use patient education material to illustrate instructions.
• Maintain confidentiality of patient information.
• Report any suspicious or unusual events.
• Review charting to ensure completeness and accuracy and to identify any discrepancies or omissions.

Documentation

• Accurate documentation is crucial for legal defense in case of claims.
• Clear, individualized, and goal-directed documentation based on assessment is important to limit nursing liability.
• Nursing care not documented is considered not given in a court of law.
• Nurses are responsible for documenting assessments, interventions, patient responses, instructions, and referrals.
• Inappropriate documentation like precharting or documenting incorrect data can lead to malpractice.

Traditional Charting

• Chart divided into sections like admission information, physician orders, progress notes, history and physical examination data, care plan, and nursing notes.

Narrative Charting

• Includes subjective and objective data about the patient's needs or problems.
• Documents care provided, treatments, and patient response.
• Nursing assessment is documented head-to-toe.

Focus Charting

• Uses the nursing process and patient needs rather than medical diagnoses.
• Focuses on current patient concerns, significant changes in status or behavior, or significant events in therapy.

Charting by Exception

• Documents complete assessments, observations, vital signs, and other pertinent data at the beginning of each shift.
• Notes are made for additional treatments, withheld treatments, changes in condition, and new concerns.
• Progress or revisions are recorded for active patient problems on the care plan.

Incident Reports

• Used for unplanned events in a healthcare facility.
• Include objective information, care given in response, and notified healthcare providers.
• Not included in the patient's medical record.

Clinical Pathways (Critical Pathways)

• Standardized, integrated care plans for patients with predictable conditions.
• Include care plans, interventions for each day of hospitalization, and a documentation tool.
• Used for monitoring patient progress.

Communication

• One of the most important aspects of nursing care.
• Interactions between nurse and patient, family, physician, or coworker.
• Effective communication minimizes miscommunication.

Overview of Communication

• Sender conveys the message, receiver receives it.
• Communication can be one-way or two-way.
• One-way communication is highly structured, with limited receiver input.
• Two-way communication involves active participation from both sender and receiver to establish a trusting relationship.

Verbal Communication

• Consists of spoken or written words or symbols.
• Words have different meanings for different people (connotation).
• Denotative meaning is the commonly accepted definition of a word.
• Nurses should use common language instead of medical terminology to avoid miscommunication.

Nonverbal Communication

• Messages conveyed without words, including tone, volume, eye contact, physical appearance, and touch.

Voice

• Tone, volume, and rate of speech influence nonverbal communication.
• Variations reflect emotion, situation, confidence, and cultural influences.
• Interpretation should consider voice characteristics in context.

Eye Contact

• Conveys intention to interact.
• Extended eye contact can be aggressive or anxiety-inducing.
• 2 to 6 seconds of eye contact during interaction is generally appropriate.
• Absence of eye contact can communicate shyness, lack of confidence, disinterest, embarrassment, or respect.
• Cultural differences influence interpretation of eye contact.

Physical Appearance

• Attributes of size, color, dress, grooming, posture, and facial expression influence perceptions.
• A professional appearance conveys self-respect and competence.
• Dress codes, jewelry, piercings, tattoos, and hair can also influence communication.

Gestures

• Movements used to emphasize communication.
• Can clarify or be negative (e.g., looking at a watch while a patient is talking).

Posture

• Body position, stance, and movement.
• Open posture conveys warmth and acceptance.
• Closed posture conveys distance and nonacceptance.

Styles of Communication

• The manner of communication influences interaction outcomes.

Assertive Communication

• Confidently and comfortably expresses thoughts and feelings while respecting the patient's rights.
• Considers the patient's needs while honoring the nurse's rights.

Aggressive Communication

• Overpowering and forceful interaction to meet personal needs at the expense of others.
• Destructive and non-therapeutic.

Unassertive Communication

• Unclear communication where no one benefits.

Establishing a Therapeutic Relationship

• Caring, sincerity, empathy, and trustworthiness are essential.
• Patient-centered interactions are more effective than equipment-focused ones.
• Trust is critical for patients to share personal information.
• Confidentiality is important, except for reporting threats of self-harm or harm to others.

Communication Techniques

Therapeutic Communication

• Facilitates a positive nurse-patient relationship and actively involves the patient.

Nontherapeutic Communication

• Hinders development of a trusting and therapeutic relationship.

Nonverbal Therapeutic Communication Techniques

Listening

• An acquired skill vital to the nurse-patient relationship.
• Requires full attention to the patient's verbal and nonverbal communication.

Active Listening

• Involves full attention to the patient's message and the opportunity for validation.

Passive Listening

• Nonverbal or verbal cues (eye contact, nodding, encouraging phrases) indicating attentiveness.

Silence

• Allows time for thought and formulating responses.

Touch

• Inherent in nursing practice.
• Must be used with discretion, considering sociocultural norms and guidelines.
• Conveys warmth, caring, support, and understanding.
• Interpretation depends on factors like duration, intensity, body part touched, culture, and relationship stage.

Verbal Therapeutic Communication Techniques

Conveying Acceptance

• Avoiding judgment on patients' values, beliefs, and lifestyle practices.
• Considers sociocultural influences.

Minimal Encouragement

• Nonverbal cues conveying interest.
• Examples: maintaining eye contact, nodding, and verbal comments like "yes" or "go on."

Closed Questioning

• Focused questions seeking specific "yes" or "no" answers.

Open-Ended Questioning

• Does not require a specific answer (cannot be answered with one word).
• Allows for elaboration.

Restating

• Repeating the main point of the patient's message for verification.

Paraphrasing

• Restating the patient's message using different words.

Communication Skills

• Clarifying seeks to understand a patient's message, asking for elaboration or more information to ensure accuracy.
• Focusing encourages a patient to focus on one designated topic for a more specific discussion.
• Reflecting encourages introspection and allows a patient to understand that their thoughts and feelings are important.
• Stating observations communicates observations of the patient back to them, helping to clarify intended messages and understand concerns.
• Offering information provides relevant data and asks for feedback to ensure the patient’s comprehension, promoting informed decision-making.
• Summarizing briefly reviews a discussion’s main points, focusing on key issues and allowing for additional information.
• Using humor can have positive physiological and psychological effects when used appropriately, however it should not be the only tool used.

Communicating with Diverse Patients

• Ventilator-dependent patients: Consider their current abilities when assessing alternative communication methods.
  • Use communication boards with alphabets, common phrases, and pictures.
• Aphasic patients: Unable to send or interpret verbal messages due to neurological damage.
  • Expressive aphasia: difficulty expressing verbal messages.
  • Receptive aphasia: difficulty understanding verbal messages.
• Unresponsive patients: Assume that all sound and verbal stimuli can be heard.
  • Encourage communication from providers, family, and friends.

Alternative Communication Methods

• Lip-reading: Interpreting mouthed words.
• Sign language: Hand and finger signals used for hearing-impaired patients.
• Paper and pencil or magic slate: Writing messages to communicate needs.
• Word or picture cards: Patients pick cards with words or pictures to communicate.
• Magnetic boards with plastic letters: Patients move letters on the board to spell words or phrases.
• Eye blinks: Predetermined system using blinks to indicate yes or no.
• Computer-assisted communication: Using a keyboard to type messages.
• Clock face communicator: Messages placed around a clock face for communication.

Cultural Considerations

• Cultural diversity: The United States is diverse with distinct languages, values, beliefs, health practices, and religions.
• Culture: Learned values, beliefs, morals, social norms, and practices shared by a group and passed through generations.
• Subcultures: Share characteristics with the primary culture but have distinct patterns of behavior and ideals.
• Cultural competence: Awareness of one's own cultural beliefs and practices and their relation to others.
  • Ethnocentrism: Belief that one's culture is superior to others.
  • Stereotypes: Generalized expectations about individuals or groups.
• Transcultural nursing: Understanding and integrating different cultures into patient care.
• Race: A group sharing biologic physical characteristics.
• Ethnicity: A group sharing a common social and cultural heritage.
• Holistic care: Treating each person individually, considering their cultural background.

Cultural Assessments

• Communication: Identify and reconcile language barriers.
  • Use diverse communication methods such as written materials, gestures, or pictures.
• Nonverbal Communication: Touch, eye contact, body language, and gestures vary across cultures.
  • Respect varying levels of personal comfort.
• Space: Cultures assign different comfort areas and meaning to personal space.
  • Be perceptive of individual needs for closeness or distance.
• Time: Measurement of time, rhythm of activities, and time orientation vary across cultures.
  • Be flexible to accommodate diverse time orientations.
• Social Organization: Cultural behavior is socially acquired.
  • Consider family structures and decision-making processes.
• Religious Beliefs: Religious and cultural beliefs are often interwoven.
  • Be aware of and respectful of religious practices and beliefs.
• Health Practices: Various health belief systems exist.
  • Biomedical: Treatment focuses on physical and chemical manipulations.
  • Folk: Illness is natural or unnatural, with treatments focused on rituals and supernatural forces.
  • Holistic: Seeks balance in physical, social, and metaphysical worlds.
  • Alternative: Nonmedical forms of therapy.
• Biologic Variations: Consider common diseases within ethnic groups and cultural dietary practices.
  • Recognize variations in nutritional practices and food preparation.

Cultural Considerations in the Nursing Process

• Consider cultural limitations when using nursing diagnoses.
• Evaluate patient behavior through the lens of their culture.
• Build respect and alliances between patient and provider beliefs.
• Make accommodations to the nursing process to meet cultural needs.

Family and Culture

• The Family: The basic unit of society.
  • Culture influences family structure, values, authority, decision-making, communication, dietary practices, and religious beliefs.
• Types of Families:
  • Nuclear Family: Traditional structure with a married couple and children.
  • Extended Family: Includes grandparents, aunts, and uncles living in the same household.

Family Structures

• Single-Parent Family: Can occur through choice or circumstances like death, divorce, separation, or abandonment. One parent assumes all responsibilities traditionally shared by two.
• Blended Family: Formed when adults remarry and bring children from previous marriages. Can experience challenges like:
  • Fear of love or trust due to past loss.
  • Child's loyalty to one parent hindering relationship with stepparent.
  • Jealousy arising during efforts to unify stepchildren.
• Social Contract Family/Cohabitation: A man and woman living together, sharing roles and responsibilities, without a legal commitment.
• Homosexual Family: Same-sex couple living together with shared responsibilities. May include biological, adopted, or foster children.
• Transgender Family: One or more parents who have undergone gender reassignment or are gender nonconforming living together with shared responsibilities.
• Adoptive Family: Similar to nuclear families with an adopted child. Adoption involves time, cost, and anxiety, but allows for fulfillment like biological families.
• Grandfamilies: Children raised by grandparents due to parental substance abuse, mental illness, deployment, incarceration, or death. Offers more stability than non-relative care.
• Foster Family: Parents are unable or unwilling to provide safe care for their children. Often because of abuse or neglect. Children may remain in foster care until they reach legal adulthood.

Family Patterns

• Autocratic: Unequal relationships with parents controlling children through strict rules.
• Patriarchal: Adult male dominates in work, finances, and decision-making.
• Matriarchal: Adult female dominates childcare, homemaking, and finances. An older female might care for children while the mother works.
• Democratic: Adult members are equals, engaging in joint decision-making, negotiation, and support for family growth.

Qualities of Functional Families

• Commitment to members' well-being.
• Appreciation and encouragement for accomplishments.
• Quality time with individual members.
• Sense of purpose.
• Harmony.
• Effective communication.
• Established values, rules, and beliefs.
• Coping mechanisms and resources.
• Effective problem-solving.
• Positive outlook.
• Flexibility and adaptability.

Stages of Family Development

• Engagement or Commitment Stage: The couple acknowledges marriage consideration, and family/friends offer support or opposition. Wedding plans, living arrangements, and finances are arranged.
• Establishment Stage: From wedding to the birth of the first child. Transition from independent to interdependent life. Challenges:
  • Learning to live together.
  • Joint decision-making.
  • Conflict resolution.
  • Communication.
  • Integrating families.
• Expectant Stage: Conception to pregnancy. Adjustments to parenthood, including:
  • Physiological and psychological changes.
  • Birth methods.
  • Employment adjustments.
  • Childcare.
  • Feeding methods.
• Parenthood Stage: Birth or adoption of the first child. Adjustments to changes in:
  • Free time.
  • Sleep.
  • Alone time.
  • Intimacy.
• Senescence Stage: The older adult years. Family remains a source of satisfaction and pleasure. Grandparents maintain a boundary between loving relationships and caring responsibilities.

Causes of Family Stress

• Lifespan Variations: Early stress can arise from unmet infant needs. Toddlers experience stress during separation from mothers. School-age children face peer pressures, parental expectations, and social struggles.
  • Common Signs of Stress in Children (Box 24.4):
    • Mood swings.
    • Acting out.
    • Eating or sleeping changes.
    • Unexplained physical symptoms.
    • Excessive clinging to parents.
    • Regression.
• Chronic Illness: Family coping depends on financial resources, stability, and support.
• Working Mothers: Daycare arrangements are crucial for working families and single parents. High-quality daycare:
  • Provides age-appropriate education.
  • Offers a spacious and safe environment.
  • Has a variety of materials and activities.
  • Has small class sizes with sufficient staff.
  • Demonstrates active staff involvement.
  • Offers positive encouragement.
• Abuse: Includes physical, emotional, financial, verbal, sexual abuse, and neglect. Children under a year old experience the highest rates, primarily inflicted by parents.
  • Risk Factors:
    • Financial strain.
    • Social isolation.
    • Low self-esteem.
    • History of abuse.
    • Overly strict and punitive parenting.
    • Immaturity.
    • Lack of self-control.
• Divorce: The effects of divorce on children are diverse and dependent on their age at the time of separation. Children may experience feelings of abandonment and loss of love from both parents.
  • Factors Impacting Divorce's Impact on Children:
    • Bitterness and conflict during the divorce.
    • The child's previous relationship with the separated parent.
    • The custodial parent's well-being.
    • The post-divorce relationship between the parents.
  • Tips for Divorcing Parents (Box 24.5):
    • Encourage children to express their feelings.
    • Avoid using children as pawns.
    • Refrain from speaking negatively about the ex-spouse.
    • Seek professional help if children require additional support.
    • Reassure children that the divorce isn't their fault.

Legal Principles and Practice

• Nursing practice is guided by legal principles, laws, moral standards, and ethical principles.
• Nurse Practice Acts govern the scope of nursing practice in each state.
• Ethical principles often impose higher standards than legal requirements.
• Legal and ethical principles protect both healthcare workers and patients' rights

Types of Law

• Criminal Law: Deals with offenses against society.
  • Results in a verdict of guilty or innocent.
• Civil Law: Cases between individuals.
  • Determines accountability or innocence.
  • Monetary settlements are assigned based on liability.

Negligence

• Refers to the absence of due care.
• Can be attributed to carelessness.
• Nurses and UAP can be charged with negligence.
• Does not require professional-level accountability or judgment.
• Failure to act with the care and knowledge of a prudent individual.
  • Examples: medication errors, patient falls, restraints, equipment injuries.

Malpractice

• Refers to professional negligence.
• Requires four elements for liability:
  • Duty: Established relationship between patient and nurse.
  • Breach of Duty: Failure to perform duty in a reasonable and prudent manner.
  • Harm: Injury or consequence resulting from the breach.
  • Proximate Cause: The breach directly led to the harm.
• Avoiding malpractice involves practicing within rules, standards, and agency policies.

Levels of Responsibility

• Individual: Personally responsible for negligence or malpractice.
• Manager/Supervisor: Responsible for inappropriate supervision or delegation.
• Employer: Can be held liable for inadequate training, credentials, or resources.

Civil Litigation Process

• Plaintiff: Filing party alleging breach of duty.
• Complaint: Formal statement outlining the facts, legal issues, and damages sought.
• Defendant: Person accused of wrongdoing.
• Summons: Legal notice served on the defendant.
• Verdict: Decision based on evidence, testimony, witness credibility, and relevant laws.
• Appeals: Request for review of the verdict by a higher court.

Criminal Trial Process

• Determines guilt or innocence of a crime against society.
• Sentence is determined based on severity, criminal history, and applicable laws.
• Appeals are possible for errors in process or court proceedings.

Legal Relationships and Accountability

• Patients can pursue charges against individuals, departments, or the facility.
• Nurses have autonomy, but are increasingly held legally accountable.
• Accountability involves responsibility for actions, leading to potential legal liability.
• Increased litigation against nurses due to:
  • Increased responsibilities and complexity.
  • Staffing shortages and budgetary constraints.
  • Patient acuity and emphasis on early discharge.

Nurse-Patient Relationship

• Established when a nurse accepts a care assignment.
• Legal duty to provide care consistent with expertise.
• Nurses act as patient advocates, safeguarding their interests.

Standards of Care and Scope of Nursing Practice

• Standards define required, permitted, and prohibited actions.
• Derived from federal and state laws, regulations, and professional organizations (ANA).
• Define nursing obligations and limitations, failure to adhere leads to liability.
• Common breaches of standards of care:
  • Practice: Improper technique or skill execution.
  • Monitoring: Failing to observe, assess, or report changes in patient condition.
  • Communication: Inadequate information sharing.
• Nurses are responsible for seeking guidance when unfamiliar with procedures.

Nurse Practice Acts

• Define and limit the scope of nursing practice.
• Vary between states, provinces, and territories.
• Employers may place additional practice limitations.
• Institutions can establish policies within state nurse practice act boundaries.

Patient Rights

• Expectations regarding health care services.
• Patient Care Partnership:
  • Adapted by institutions to meet their needs.
  • Promotes public understanding of rights and responsibilities.
• The Joint Commission: Accredits and certifies healthcare facilities.

Patient Self-Determination Act

• Requires institutions to have policies regarding:
  • Advance directives.
  • Right to accept or refuse treatment.
  • Participation in health-care decisions.

Health Insurance Portability and Accountability Act (HIPAA)

• Sets rules and limits on accessing and disclosing patient health information.
• Penalties for wrongful disclosure of Protected Health Information (PHI).

Health Care Institution Obligations

• Provide access to care without discrimination.
• Offer respectful and dignified treatment.
• Ensure privacy, confidentiality, and safety.
• Provide complete information about condition and care.

Patient Responsibilities

• Provide accurate information about themselves.
• Share information about known conditions.
• Participate in treatment decisions.

Informed Consent

• Patient's right to make health care decisions.
• Full disclosure of information needed to make informed decisions about treatment or procedures.
• Right to accept or refuse treatment after understanding benefits, risks, alternatives, and consequences.
• Failure to obtain informed consent can lead to civil liability for battery.
• Patients can withdraw or limit consent at any time.
• Written consents are required for invasive procedures.
• Valid consent requires:
  • Age 18 or older.
  • Minors with specific legal status (marriage, emancipation, independent living, military).
  • Mental competency (not impaired by alcohol or drugs).
• Information disclosure is the responsibility of the physician or nurse practitioner.
• Nurse only witnesses the signature and does not provide information.

Confidentiality

• Duty to protect patient information, regardless of storage method.
• Accessed on a need-to-know basis.
• Violations result in legal liability, civil or criminal charges, and potential termination.
• Applies to all information acquired by a nurse, both on and off duty.
• Secure storage is the responsibility of the nurse.
• Log out of computerized patient files to prevent access by others.
• Protect written notes and chart forms in restricted areas.
• Protected Health Information (PHI):
  • Identifies individuals beyond name.
  • Includes admission/discharge dates, social security number, photographs, addresses, phone numbers, date of birth, age 89 or older.

Social Media

• Online and mobile tools for sharing information.
• Healthcare facilities have policies regarding smartphone and device use.
• Violations often involve blurring boundaries between nurse and patient.
• Posting information about patients, families, or the facility can result in discipline or termination.

Medical Records

• Laws govern the collection, maintenance, and disclosure of information.
• Each institution has policies and procedures.
• Are not public documents, information must be kept secure.
• Breaches in confidentiality can lead to legal liability.
• Used in lawsuits to argue facts and assess standard of care adherence.

Invasion of Privacy

• The legal concept of invasion of privacy involves a person's right to be left alone and remain anonymous.
• Consent for treatment does not waive the right to privacy.
• Privacy-related concerns may include the physical exposure or disclosure of patient information to others.

Reporting Abuse

• Health care professionals are mandated reporters of child abuse.
• Failure to report suspected cases of child abuse can result in fines or imprisonment.
• Withholding medical treatment of an infant born with serious life-threatening handicaps is considered child abuse.
• The Child Abuse Prevention Treatment Act made reporting of child abuse mandatory.
• Women and older adults are at increased risk for spousal and elder abuse.

Workplace Violence

• Workplace violence includes verbal abuse, emotional abuse, sexual harassment, physical assault, and threatening behavior.

How to Avoid a Lawsuit

• Providing compassionate, competent nursing care is the best defense against a lawsuit.
• Following the standards of care and facility policies and procedures reduces the likelihood of a lawsuit.
• Remaining current on practice developments and pursuing continuing education opportunities ensures competence.
• Good Samaritan laws may limit liability for nurses who offer assistance outside of a medical facility, but state laws vary.
• Thorough documentation in the medical record is crucial for assessing liability.

Disciplinary Process

• Nurses who receive a letter from the board of nursing alleging breaches of standards of care or patient safety infractions should seek legal representation.
• Potential sanctions against a nursing license can range from a dismissed charge to revocation of the license.

Ethics

• Nursing ethics involves moral values and principles that affect personal and professional conduct.
• Nursing ethics outlines the duties and obligations of nurses to patients, other health care professionals, the profession, and society.

Advance Directives

• Advance directives are documents that provide specific instructions for health care treatment if a person is unable to make decisions personally.
• The two basic types of advance directives are living wills and durable powers of attorney for health care.
• It is important to understand patients' cultural beliefs and values when explaining advance directives.
• For advance directives to be enforceable, the patient must be legally incompetent or lack capacity to make healthcare decisions.

Living Will

• A living will is a written document that directs treatment in accordance with the patient's wishes in the event of a terminal illness or condition.
• Following the directions of a living will provides immunity from liability for health care workers.

Durable Power of Attorney for Health Care

• A durable power of attorney for health care designates an agent to make healthcare decisions on the patient's behalf, based on the patient's wishes.

Autonomy

• Autonomy gives the patient the right to refuse medical treatment.

Development of Ethical Principles

• Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude.
• Value clarification involves reflecting on and assessing one's own values.
• Ethical dilemmas are situations that do not have a clear right or wrong answer.

Ethical Principles in Nursing Practice

• Respect for people is the most fundamental ethical principle, viewing all human life as sacred with inherent worth.
• Autonomy refers to freedom of personal choice and the right to make decisions independently.
• Beneficence means doing good or acting for someone's good.
• Nonmaleficence means to do no harm.
• Justice refers to fairness and the concept that all patients have the same right to nursing interventions.

Code of Ethics

• Professional organizations have developed codes of ethics for the nursing profession to regulate nurses' actions and provide guidelines for ethical behavior.

Reporting Unethical Behavior

• Nurses have a duty to report behavior that does not meet established standards.
• Unethical behavior can include failing to perform the duties of a competent, caring nurse.
• When reporting unethical behavior, follow the proper chain of command and present facts without personal opinions.

Ethical Issues in Health Care

• Ethical issues change as society changes.

Practitioner-Assisted Suicide (PAS)

• PAS is also called active euthanasia.
• Each state has the ability to legalize or ban assisted suicide.
• PAS is not consistent with the philosophy of nursing, based on the principles of nonmaleficence and beneficence.
• PAS supporters cite the ethical principles of autonomy and self-determination.

Right to Refuse Treatment

• Competent adults have the right to refuse treatment.
• Patients may prepare advance directives to exercise their right to refuse treatment.

Do-Not-Resuscitate Orders (DNR)

• DNR orders are written by a physician after consultation with the patient's family, when the patient is incapacitated and there is little hope for recovery.
• The nurse has a duty to follow DNR orders.

Refusal to Treat

• Refusal to treat arises when a patient's care requires a nurse to do something that conflicts with their personal moral beliefs.
• Nurses have a duty to uphold the ethical principle of respect for all people without discrimination.

Patient Records

• The patient chart (health record) is a legal record that meets the demands of many systems.
• Documentation in the chart is referred to as charting, recording, or documenting.
• Proper documentation covers all areas of patient needs and concerns.

Electronic Health Record (EHR)

• The EHR includes nursing care and interventions, information for management of admissions, billing, and communication of orders.
• A benefit of HER is the ability for all health care providers to view a patient's record.
• HER systems are more efficient as information can be automatically transferred to other areas within the facility.

SBAR (Situation, Background, Assessment, and Recommendation)

• SBAR is a method of communication among health care workers and a part of documentation.
• SBAR is considered a safety measure to prevent errors from poor communication.

Basic Guidelines for Documentation

• Accurate documentation has a direct impact on the success or failure of communication.
• Documentation should include the type of intervention, the time care was rendered, and the signature and title of the person providing care.

Documentation

• Accurate documentation is essential for quality patient care and serves as a legal defense in case of claims.
• The LPN/LVN must ensure the information in the patient's health record is clear, concise, complete, and accurate.
• The registered nurse is primarily responsible for initial admission nursing history, physical assessment, and care plan development based on identified healthcare problems.
• Inadequate documentation can lead to legal issues, as a court may assume care was not provided if it is not documented.
• The nurse must record all assessments, interventions, patient responses, instructions, and referrals in the medical record.
• Inappropriate documentation, such as documenting care in advance or incorrect data, can result in nursing malpractice.

Methods of Recording

• Traditional Charting: Divided into sections like admission information, physician's orders, progress notes, and lab reports.
• Narrative Charting: Includes subjective and objective data about patient needs and problems, care provided, and responses to treatment.
• Focus Charting: Utilizes the nursing process and patient needs, focusing on current concerns, changes in status, or significant events.
• Charting by Exception: Documents complete assessments and vital signs at the beginning of shifts, only noting deviations or changes in patient condition.

Incident Reports

• Used for unplanned occurrences, like falls or medication errors, within a healthcare facility.
• Report objective, observed information only, avoiding unnecessary details.
• Include care given in response to the incident and the name of the notified healthcare provider.
• Do not include the incident report in the patient's medical record or nurses' notes.

Documentation and Clinical Pathways

• Clinical pathways are standardized, integrated care plans for specific case types, often used in managed care settings.
• They provide a framework for coordinating medical and nursing interventions.
• Each pathway includes a care plan, interventions, and a documentation tool, replacing other nursing forms.
• Documentation focuses on deviations from the anticipated interventions.

Communication

• Communication is crucial in nursing, involving verbal and nonverbal exchanges between nurses and patients, families, and colleagues.
• Effective communication minimizes miscommunication.
• One-way Communication: Highly structured, sender-controlled, with limited receiver response. Not ideal for nurse-patient relationships.
• Two-way Communication: Requires active participation from both sender and receiver, fostering trust and meeting needs.
• Verbal Communication: Uses words, symbols, and written language, where connotations and denotative meanings can vary between individuals.
• Nonverbal Communication: Conveys messages using tone, eye contact, appearance, gestures, and touch.

Nonverbal Communication

• Voice: Tone, volume, and rate of speech can convey emotion, confidence, and cultural influences.
• Eye Contact: Indicates intention to interact, but prolonged contact can be perceived as aggression.
• Physical Appearance: Dress, grooming, posture, and facial expressions influence perceptions.
• Gestures: Movements used to emphasize ideas, but some can be misinterpreted.
• Posture: Open posture conveys warmth and acceptance, while closed posture may indicate disinterest or coldness.

Styles of Communication

• Assertive Communication: Confidently expressing thoughts and feelings while respecting others' rights.
• Aggressive Communication: Overpowering and forceful communication to meet one's own needs at the expense of others.
• Unassertive Communication: Open but often ineffective communication where needs are not met.

Establishing a Therapeutic Relationship

• Therapeutic communication involves empathy, caring, trustworthiness, and a patient-centered approach.
• Trust is essential for patients to share personal information, and confidentiality is crucial.

Communication Techniques

• Therapeutic Communication: Fosters a positive nurse-patient relationship and active patient involvement.
• Nontherapeutic Communication: Blocks the development of a trusting and therapeutic relationship.
• Minimal Encouragement: Conveys interest and motivates the patient to share more.
• Closed Questions: Focused questions requiring concise or "yes/no" responses.
• Open-Ended Questions: Encourage elaboration and exploration of feelings.
• Restating: Repeating the patient's main point to ensure understanding.
• Paraphrasing: Restating the patient's message using different words.
• Silence: Allows time for reflection and thought processing, but can be uncomfortable if used excessively.
• Touch: A powerful nonverbal communication tool that can be interpreted differently depending on cultural and personal contexts.

Communication Techniques

• Clarifying aims to ensure the nurse understands the patient's message completely.
• Focusing helps concentrate the conversation on specific topics for better understanding.
• Reflecting encourages patients to analyze their thoughts and feelings.
• Stating Observations helps clarify any discrepancies between verbal and nonverbal cues.
• Offering Information involves providing patient-relevant information and seeking feedback for comprehension.
• Summarizing revises key points of a discussion.
• Using Humor can be therapeutic but must be used appropriately.

Communication Challenges

• Ventilator-dependent Patients: May rely on communication boards, alphabet charts, or picture systems.
• Aphasic Patients: May have difficulty expressing or understanding verbal messages.
• Unresponsive Patients: Assume they can hear all sound and verbal cues.
• Alternative Communication Methods: Include lip-reading, sign language, paper & pencil, word/picture cards, magnetic boards, eye blinking, and computer-assisted communication.

Cultural Competency

• Cultural Competence: Acknowledging and respecting differences in beliefs and practices.
• Ethnocentrism: Belief that one's culture is superior to others.
• Stereotype: Generalized assumption about individuals or groups.
• Transcultural Nursing: Understanding and integrating cultural variations into patient care.

Cultural Influences

• Communication: Language barriers may require translators, alternative methods, and sensitivity to cultural cues.
• Space: Different cultures have varying comfort levels with personal space.
• Time: Temporal concepts and time orientation vary across cultures.
• Social Organization: Family structures and decision-making processes are influenced by culture.
• Religious Beliefs: Religious practices affect healthcare choices and treatment approaches.
• Health Practices: Biomedical, folk, holistic, and alternative health systems coexist.
• Biologic Variations: Ethnicities may have predispositions to certain diseases.

Family Dynamics

• Family as a Unit: The family is the primary unit of society with various functions and responsibilities.
• Types of Families: Include nuclear, extended, blended, and adoptive families.
• Family Roles and Responsibilities: Protection, nurturance, education, sustenance, socialization, affection, acceptance, companionship, and fostering growth and development.

Single-Parent Family

• Exists by choice or due to death, divorce, separation, or abandonment.
• The single parent, regardless of gender, assumes all the responsibilities typically shared by two parents.

Blended Family

• Also known as a stepfamily, formed when adults remarry and combine children from previous relationships.
• Presents potential stress:
  • Fear of love and trust due to past loss.
  • Children's loyalty to one parent might hinder their relationship with the stepparent.
  • Jealousy may arise when integrating stepchildren into one family.

Social Contract Family/Cohabitation

• A couple living together, sharing roles and responsibilities, without legal commitment.

Homosexual Family

• Involves a same-sex couple living together, sharing responsibilities.
• May include biological, adopted, or foster children.

Transgender Family

• May have one or more parents who have undergone gender reassignment or are gender-nonconforming.
• Parents live together with shared responsibilities.

Adoptive Family

• Often a nuclear-style family with an adopted child.
• Adoption can be time-consuming, stressful, and expensive, but provides fulfillment comparable to biological families.

Grandfamilies

• Children living with or under the custody of grandparents.
• Often due to parental substance abuse, mental illness, military deployment, incarceration, or parental death.
• Research suggests children raised by grandparents or other family members experience more stability and safety than those placed with non-relatives.

Foster Family

• Occurs when biological parents are unable or unwilling to provide adequate and safe care for their children.
• Often court-ordered due to abuse or neglect.
• If possible, parents are given time to stabilize to regain custody. Otherwise, children remain in foster care until legal adulthood.

Family Patterns

• Refer to the way family members interact.
• Autocratic: Unequal relationships, parents control children with strict rules.
• Patriarchal: The adult male dominates in work, finances, and decision-making.
• Matriarchal: The adult female dominates in childcare, homemaking, and finances.
• Democratic: Adult members are equal, engaging in joint decision-making, negotiation, compromise, support, and family growth.

Functional Family Qualities

• Commitment to members' well-being.
• Appreciation and encouragement for accomplishments.
• Quality time with individual members.
• Sense of purpose guiding progress during good and difficult times.
• Harmony among members.
• Effective communication.
• Established values, rules, and beliefs.
• Diverse coping mechanisms and resources to enhance functioning.
• Effective problem-solving methods.
• Positive outlook.
• Flexibility and adaptability.

Stages of Family Development

• Engagement/Commitment: Couple acknowledges considering marriage, seeking support or opposition from friends and family, planning wedding, living situation, work, and home goods.
• Establishment: Spans from the wedding to the first child's birth, transitioning from single independence to married interdependence. Challenges include learning to live together, joint decision-making, conflict resolution, communication, and integrating families. Successful marriage requires time and energy dedicated to commitment, goals, and mutual respect.
• Expectant: Begins with conception and continues throughout pregnancy. Requires adjustments and decisions regarding physiological and psychological changes, childbirth methods, employment status, childcare, and feeding methods. Surrogacy may be considered, involving a third-party agreement for artificial insemination and subsequent relinquishment of parenting rights.
• Parenthood: Starts with the birth or adoption of the first child, requiring adjustments to limited free time, sleep, alone time, and intimacy. Parental anxiety regarding competency in their new role is common. Disengagement occurs when grown children leave the home. The parenting role evolves to provide continued emotional and financial support, though the parent needs to redefine their personal roles for a sense of purpose, achievement, and self-fulfillment.
• Senescence: Final stage of the life cycle, encompassing older adult years. Family remains a source of satisfaction and pleasure. Grandparents balance independence with time spent with their family, maintaining boundaries and nurturing a close relationship with grandchildren without caregiving responsibility. Women often outlive their spouses due to longer life expectancies.

Causes of Family Stress

• Lifespan Differences: Stress in early infancy arises from unmet needs. Toddlers experience stress during separation from their mothers. School-age children face stressors from school pressures, parental expectations, and social interactions. Children may display signs of stress including: mood swings, acting out, altered eating and sleeping patterns, frequent physical complaints (stomach aches, headaches), excessive clinging to parents, thumb-sucking, bedwetting, regression to earlier developmental stages. Parents are advised to anticipate stress and prepare children by validating feelings, reassuring that distress is normal, and offering potential solutions.
• Chronic Illness: Family's ability to cope with chronic physical or mental illness depends on financial resources, stability, and support.
• Working Mothers: Childcare arrangements are crucial for dual-income families or single-parent households. High-quality daycare facilities offer age-appropriate educational structure, an open and spacious environment, diverse materials and activities, small class sizes, appropriate staff-to-child ratios, active staff involvement, and positive encouragement.
• Abuse: Abuse encompasses physical, emotional, financial, verbal, sexual abuse, and neglect. Children under one year old experience the highest victimization rates, often by a parent. Risk factors include financial strain, social isolation, low self-esteem, history of abuse, overly strict and punitive parenting with unreasonable expectations, immaturity, and lack of self-control. Prompt recognition, reporting, and preventative measures are crucial to identify and stop abuse and neglect.
• Divorce: Divorce's impact on children is complex and varies depending on their age at separation. They may feel abandoned or unloved by both parents. Reconciliation fantasies often persist long after the divorce is finalized. Factors influencing the impact include bitterness and conflict during divorce, the child's pre-existing relationship with the separated parent, the divorce's effect on the custodial parent, and the post-divorce relationship between parents. Divorce brings significant changes to the emotional environment, family roles, finances, lifestyle, and even the neighborhood familiar to the child. Parents are advised to encourage their children to express their feelings, avoid using them as pawns, refrain from speaking negatively about the ex-spouse in their presence, seek professional help for additional support, and reassure children that the divorce is not their fault.

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