PENERAPAN ETIK & LEGAL DLM

PRAKTIK KEPERAWATAN
PROFESIONAL

Oleh: Prof. Dr.Nursalam,M.Nurs (Hons)

Etik Nursalam-2010

Etik Nursalam-2010

PENGANTAR & MASALAH

Etik profesi merupakan prinsip prinsip moral atau asas-asas yang harus
diterapkan oleh perawat dalam hubungannya dengan pasien, teman sejawat dan
masyarakat uymumnya. Etik ini mengatur tentang perilaku profesional paa perawat
dalam menjalankan pekerjaannya, sebagaimana tercantum dalam lafal sumpah dan
kode etik perawat yang disusun organisasi profesional bersama pemerintah.
Pelanggaran etik keperawatan tidak selalu berarti pelanggaran hukum, demikian
pula sebaliknya. Pelanggaran etik keperawatan diproses melalui MKEK-PPNI dan jika
diperlukan diteruskan ke Departemen Kesehatan. Sedangkan pelanggaran hukum
diselesaikan melalui pengadilan.
Untuk menghindari pelanggaran etik dalam praktik keperawatan profesional,
maka perawat harus menerapkan prinsip / azas etik dan kode etik serta mematuhi
aspek legal keperwatan yang diatur dalam KepMenkes 148/2010 dan UU Kes 36/2009.
Dalam melaksanakan perawat harus memperhatikan dan menghindari yang disebut
dengan negligence (kealpaan): commision dan ommision. Hal ini bisa dilakukan apabila
perawat dalam setiap mengambil keputusan etik selalu didasarkan pada ethical decision
making dan clinical decision making.
SISTEM REGULASI DALAM PRAKTIK KEPERAWATAN
SOSIAL
Regulasi Profesi
Legal Regulasi
Definisi Lingkup praktik
State Nursing Practice
Acts (UU Praktik)
Standar
Profesional

Standar professional
untuk pendidikan

Akreditasi
Program
Pendidikan

Board Regulasi
Keperawatan

Stndar professional,
tujuan, kebijakan,
prosedur pelayanan
keperawatan.
Sertifikasi pada
bidang kekususan
keperawatan

Akreditasi
organisasi
pelayanan
keperwatan

Lisensi

Perlindungan publik
Penjaminan
Mutu

KLIEN

Lindberg (1990: 320)

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APA PENYEBAB DARI MASALAH ETIK?

lack of formal education
lack of institutional for review dilemmas
perceived lack of peer support
concern about reprisals
lack of perceive decision making authority

TANTANGAN ETIK KEPERAWATAN

1. Dasar-dasar moral makin memudar
2. Dasar & sendi agama makin menipis
3. Perkembangan IPTEK yg meningkat
4. Globalisasi yg menyebabkan persaingan bebas (orientasi pelayanan dari sosial bisnis)
5. Kamajuan & perkembangan masyarakat sebagai pengguna jasa: (kesadaran
hak; tk. Ekonomi yg meningkat; kesenjangan si kaya dan si miskin; IPTEK
meningkat)
6. Perubahan dlm. Masyarakat perawat (kurangnya kemampuan - etik; masuknya
tenaga LN)
KONSEP ETIK KEPERAWATAN
ETHICs
. doing good and avoiding harm
(Bandman & Bandman, 1995:5)
good and bad, moral duty, obligation and values
(Lindberg, 1990: 295)
VALUES
. A belief or custom that frequently arises from cultural or ethical background,
family adaptation, peer group ideas and
(Lindberg, 1990: 254).
PERKEMBANGAN MORAL

The Golden Rule

National Morality

Level 1

Compliance to societal authority

Behavior to satisfy and win
approval of those authority

Level 2

Deference to power of certain values

Performance to avoid punishment

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Level 3

PERBEDAAN ETIK DAN HUKUM KEPERAWATAN

Etik
. doing good and avoiding harm (Bandman & Bandman, 1995:5)
Apa yang harus dilakukan manusia
Apa yang seharusnya dilakukan kepada seseorang
Suatu analisa proses terhadap suatu tindakan
Berdasarkan ilmu dan nilai / norma di masyarakat
Hubungan etik dgn.
MORAL (apa yg dinilai baik /buruk oleh masyarakat)
HUKUM (legalisasi sikap tindak etik)

ETHIC
BEHAVIOR

Cognitive
affective
psychomotor

observed A
recorded C
measured U

Cipta : (the truth)

Rasa : (the beauty)
Karsa : ( goodness)
UKURAN GOOD / BAD TINDAKAN MANUSIA
KRITERIA

Dilakukan Dengan Sengaja

Dilakukan Dengan Kesadaran
Yang Bersangkutan Telah Mengetahui
Yang Bersangkutan Mempunyai Pilihan

UKURAN BAIK DAN BURUK (SECARA UNIVERSAL)

Hedonisme (kenikmatan & kepuasan rasa)
Utilitarism (bermanfaat)
Vitalisme (kekuatan dan kekuasaan)
Sosialisme (masyarakat yg menentukan)
Religionisme (firman Tuhan)
Humanisme (hak asasi manusia)
TEORI ETIK
1. Utilitarianism
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 . Greatest happiness principles ,

2. Deonotology
. Ringhtness or wrongness of an action depended on the inherent moral
significance of the action
. To do ones duty was right, not to do ones duty was wrong (selalu memegang
janji, dan tak pernah berbohong sesuai dengan situasi)

PERBEDAAN SCIENTIFIC AND ETHICAL

SCIENTIFIC
Tujuan : menjelsakan peristiwa
kesimpulan : benar dan salah
adanya penjelasan dan penjabaran

ETHICAL
Justifikasi tindakan manusia
tidak bisa secara langsung : benarsalah
obligations atau pernyataan yang
harus dikerjakan

A GOOD NURSE IS ONE WHO...

Personal characteristic
Professional characteristic
Patient centeredness
Advocacy
Competence
Critical Thinking
Patient care
ETHICAL NURSING CARE IS..

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PRINSIP & AZAS ETIK KEPERAWATAN

1.
2.
3.
4.
5.

JUSTICE (Asas Keadilan)

AUTONOMY
BENEFICIENCY & NON-MALEFICIENCY
VERACITY
CONFIDENTIALITY

1. JUSTICE (Asas Keadilan)

equals should be treated the same and unequals should be treated differently.
Pasien harus diperlakukan sama sesuai dengan keadaan sakitnya,
tidak ada diskriminasi ( pasien, alat - alat, dll )
Models ( health care resources )
Setiap arang sama
berdasarkan jasa
keberadaan peralatan
sesuai kebutuhan
2. AUTONOMY (Asas menhormati otonomi)
Individuals have the right to determine their own actions
Karakteristik :
Sesuai dengan nilai - nilai / kepercayaan
informasi yang cukup
bebas dari coercion
berdasarkan alasan dan kebebasan
3. BENEFIENCE (asas manfaat) DAN NON-MALEFICIENCY (tidak merugikan)
Doing or promoting good
Karakteristik :
Nonmaleficence
mencegah harm atau kesalahan
mengurangi / menghilangkan harm or evil
promote good
4. VERACITY (Asas Kejujuran)
.. Telling the truth
5. CONFIDENTIALITY Kerahasaiaan
Perawat harus merahasiakan keadaan pasien, meskipun pasien sudah meninggal
kecuali diminta oleh institusi yang berkompeten.
6. RESPECT FOR PERSONS (Asas perbedaan tiap individu)
Eeach person shpuld be treated as a unique individual and as a member of the
human
community
7. FIDELITY (Asas Komitmen)
one has a moral duty to be faithful to the commitments that one makes to others

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KODE ETIK KEPERAWATAN DI INDONESIA (PPNI)

(Code Of Ethics For Nurses Indonesia)
LIMA PRINSIP:
1. Perawat dan pasien
2. perawat dan praktik
3. perawat dan masyarakat
4. perawat dan teman sejawat
5. perawat dan profesi
PERAWAT DAN KLIEN
1. Perawat dalam memberikan pelayanan keperawatan
2. Menghargai harkat dan martabat manusia, keunikan klien, dan tidak terpengaruh
oleh pertimbangan kebangsaan, kesukuan, warna kulit, umur, jenis kelamin,
aliran politik dan agama yang dianut serta kedudukan sosial.
3. Perawat dalam memberikan pelayanan keperawatan senantiasa memelihara
suasana lingkungan yang menghormati nilai-nilai budaya, adat-istiadat dan
kelangsungan hidup beragama dari klien.
4. Tanggung jawab utama perawat adalah kepada mereka yang membutuhkan
asuhan keperawatan.
5. Perawat wajib merahsiakan segala sesuatu yang diketahui sehubungan dengan
tugas yang dipercayakan kepadanya kecuali jika diperlukan oleh yang
berwenang sesuai dengan ketentuan hukum yang berlaku.
PERAWAT DAN PRAKTIK
1. Perawat memelihara dan meningkatkan kompetensi dibidang keperawatan
melalui belajar terus menerus.
2. Perawat senantiasa memelihara mutu pelayanan keperawatan yang tinggi
desertai kejujuran profesional dalam menerapkan pengetahuan serta
keterampilan keperawatan sesuai dengan kebutuhan klien.
3. Perawat dalam membuat keputusan didasarkan pada informasi yang adekuat
dan mempertimbangkan kemampuan serta kualifikasi seseorang bila melakukan
konsultasi menerima delegasi dan memberikan delegasi kepada orang lain.
4. Perawat senantiasa menjunjung tinggi nama baik profesi keperawatan dengan
selalu menunjukkan perilaku profesional.
PERAWAT DAN MASYARAKAT
Perawat mengemban tanggung jawab bersama masyarakat untuk memprakarsai dan
mendukung berbagai kegiatan dalam memenuhi kebutuhan kesehatan masyarakat.
PERAWAT DAN TEMAN SEJAWAT
1. Perawat senantiasa memelihara hubungan baik dengan sesama perawat
maupun dengan tenaga kesehatan lainnya, dan dalam memelihara keserasian
suasana lingkungan kerja maupun dalam mencapai tujuan pelayanan kesehatan
secara menyeluruh.
2. Perawat bertindak melindungi klien dan tenaga kesehatan yang memberikan
pelayanan kesehatan secara tidak kompeten, tidak etis dan illegal.
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PERAWAT DAN PROFESI

1.

Perawat mempunyai peran utama dalam menentukan standar pendidikan dan

pelayanan keperawatan serta menerapkan dalam kegiatan pelayanan dan
pendidikan keperawatan.

2.

Perawat berperan aktif dalam berbagai kegiatan pengembangan profesi

keperawatan.

3.

Perawat berpartisipasi aktif dalam upaya profesi untuk membangun dan

memelihara kondisi kerja yang kondusif demi terwujudnya asuhan keperawatan
yang bermutu tinggi.

INDICATORS NEGLIGENCE (4D)

D1 Duty (Nurse had specific professional duty to patient)

D2 Direlection (Nurse did not carry out his/her duty)
D3 Damage (Nurse caused injury to his/her patient)
D4 Direct Causation (The patients injury resulted from the nurses negligent
action)

Tujuah (7) pitfalls yang umum terjadi Pada aspek etik keperwatan dan hukum
kesehatan.
1.
2.
3.
4.
5.
6.
7.

Patient falls
Failure to follow up MD. orders/protocol
Medication error
Improper use of equipment
Failure to remove foreign objects
Failure to provide sufficient monitoring
Failure to communicate

BAGAIMANA MENGHINDARI NEGLIGENCE

C
= CHECK THE ORDER
W
= WASH YOUR HANDS
I
= IDENTIFY THE PATIENT
P
= PROVIDE SAFETY & PRIVACY
A
= ASSESS THE PROBLEMS
T
= TEACH & TELL THE PATIENT

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INFORMED CONSENT
Consent : (latin: consensio, con sentio), berarti persetujuan, ijin, menyetujui, memberi ijin
kpd seseorang utk melakukan sesuatu.
Permenkes (1989).
Informed Consent: persetujuan yg diberikan oleh pasien atau keluarga atas
dasar penjelasan mengenai tindakan medik yg akan dilakukan thd pasien tsb
A. UNSUR INFORMED CONSENT
1. CAPACITY (Kemampuan Memahami Informasi)
Ciri:
- Memiliki Nilai & Tujuan
- Kemampuan berkomunikasi &
memahami informasi
- Kemampuan membuat alasan atas pilihannya dan keputusan
2. VOLUNTERINISM (sukarela)
Ciri:
- tanpa paksaan
- tanpa ancaman
3. UNSUR INFORMASI
Ciri:
Diagnosis / masalah pasien
tujuan dan lama tindakan
hasil
manfaat
potensial resiko
alternatif tindakan sesuai kemampuan
prognosa jangka pendek & panjang
B. TUJUAN I.C
1. Perlindungan pasien utk segala tindakan (tindakan yg tidak perlu o/tim tanpa
sepengetahuan pasien)
2. Perlindungan tenaga medis dan perawat akibat penyakit tidak terduga serta
dianggap merugikan pihak lain
C. FUNGSI I.C
1. Promosi dari hak otonomi perorangan
2. Proteksi dari pasien dan subjek
3. Mencegah penipuan atau paksaan
4. Rgs. Profesi kes. Introspeksi
5. Promosi dari keputusan rasional
6. Keterlibatan masyarakat (otonomi nilai sosial & pengawasan)
D. BENTUK I.C
1. Express lisan & tertulis
2. Tersirat (implied or tacit consent)
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- dlm keadaan biasa

- dlm keadaan gawat darurat

E. PEMBERI I.C
1. Asien dewasa (sadar & sehat mental)
2. Pasien dewasa (21 th atau sudah menikah)
3. PAsien dewasa (pengampunan) oleh orang tua
4. Pasien dewasa (ggn mental) oleh orang tua/wali
5. Pasien dibawah 21th (tidak ada ortu) oleh keluarga terdekat
F. PENGABAIAN I.C
1. Tidak ada kesempatan memintakan
2. Tidak ada waktu lagi utk menunda-nunda tindakan
3. Untuk menyelamatkan nyawa, tidak mempunyai penyakit sebelumnya
4. Melindungi keselamatan anak/bayi
5. Mencegah self-distruction
6. Melindungi kes. Masyarakat
7. Menjaga etik / aturan RS
(UU-Kes 23/1992, pasal 53)
G. KRITERIA GAWAT (I.C)
1. Shock
2. Perdarahan
3. Patah Tulang
4. Kesakitan (Pain)
(PERMENKES 585/1989: dalam hal pasien tidak sadar/pingsan serta tdk
didampingi o/ kel.
Terdekat dan sec. medik dlm keadaan gawat dan atau
darurat yg memerlukan dindakan
medik segera utk kepentingannya, tidak
diperlukan persetujuand dari siapapun)
H. I.C TIDAK SAH JIKA . .. .
1. Dengan paksaan (duress, dwang)
2. Krn memberikan informasi yg salah/berlainan
3. Dari seseorang yg belum dewasa
4. Dari seseorang yg tidak berwenang
5. Dalam keadaan tdak sepenuhnya sadar (non lucid state)

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EDM (ETHICAL DECISION MAKING) IN NURSING

DECISION MAKING
End point of using critical thinking and scientific resoning ethical in problem
reasoning.
Even no decision is decision, because , in effect, it is supports the existing state
of affairs

ETHICAL DECISION MAKING ( EDM )

PERAWAT

PASIEN

KELUARGA

TENAGA KES. LAINNYA

PERBEDAAN PROSES KEPERAWATAN DAN EDMM

ETHICAL DECISION MAKING MODEL
Klarifikasi ethical dilemma
Mengumpulkan data tambahan
Identifikasi pilihan
Membuat suatu keputusan
Act ( tindakan )
Evaluate

PROSES KEPERAWATAN
assess
analyse
plan
implement
evaluate

SOURCES OF DILEMMAS (ETHICAL CONFLICT )

Personal & Prof. values

Client & Prof.

Values

Values among Health Behavior

Janice, B. Lindberg (1990: 311)

STRATEGY E-D-M
FORMULA:
THEORIES + VALUES + SITUATIONAL
DATA
Utilitarism
Deontological

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Janice, B. Lindberg (1990: 311)

SITUATION DATA
Determine what health problems and individual person strength exist
Identify what decision need to be made
Separate the ethical component of the decisions from those issues
Identify all the individual and groups who will be affected.
ACCOUNTABILITY
Means responsibility or the obligations to account for ones behavior or act
Objective:
Assume responsibility for his or her own actions
Demonstrate self-discipline in meeting commitments and obligations
(appointment)
Prepare in advance for clinical experience
Reposrt unsafe client-patient practice
ASSUMPTIONS
All nursing practice involves EDM
Person centered care demands a willingness to confront ED
Personal & professional values influence ED
Persons (care givers and clients) can be assisted to achieve higher levels of
moral reasoning
There is no one correct ethical theory

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FORMULA DASAR PENGAMBILAN KEPUTUSAN ETIK

LEGAL
UU KES
36/2009 dan
KepMenkes
148/2010

ETIK
AZAS & KODE ETIK

NILAI-NILAI
(Agama, budaya,
Dll)

SOLUSI

Masalah
Etik

LANGKAH PENGAMBILAN
KEPUTUSAN

1
Klarifikasi
Delima etik

6
Evaluasi

2
Pulta

3
Identifikasi
Pilihan

Pelaksanaan

Keputusan

Institusi

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CONTOH KASUS EDM

1. CONTINUE OR STOP TREATMENT
A severe asphyxia patient was in ICU for a couple days and there was no
progression. Patient's family knew that the patient was still alive because of ventilator
assistance. The family decided to stop the ventilator. "Let the patient die. We could
not afford for the cost." It was a dilemma for me. I believed the treatment must be
continued because I had duties to help the patient to survive. If the patient would die,
it was not our will. But, I had to follow the patient's family. Why didn't they want to
continue the treatment? Even though the possibility of surviving for the patient was
low, I did not want to disconnect the tube. It seemed like I killed the patient
2. WHO SHOULD GET THE VENTILATOR?
There were two patients, head injury and brain tumor patients, admitted to ICU. Head
injury patient was coma, had high level of PCO2, and RR 32 times per minutes.
Brain tumor patient was also coma, RR 26 times per minutes, and sometimes he had
apnea attack. They needed ventilator at the same time. We just had only one
ventilator. At that time, it was difficult to decide which patient should get the
ventilator. Which patient I had to help first?
3. WANT TO TAKE AN ACTION BUT BEYOND AUTHORITY
I had a situation when the patient's blood pressure was dropped and I wanted to
take action to help the patient immediately but I could not do it without reporting to
doctor firstI had to wait for order from doctor because it was beyond my
responsibility
4. TELL OR NOT TO TELL THE TRUTH
A patient's husband asked me not tell his wife that their baby died during caesarian
section. He was afraid it would make his wife's condition worse. So at that time it was
difficult for me to make a decision. Then his wife came to me and asked about her
baby. It was difficult whether or not to tell the truth to her. Her husband asked me not
to tell her. He wanted to tell his wife at their home. If I didn't tell her, I felt guilty
because it conflicted with my values. Meanwhile, doctor also suggested not to tell the
patient because he was worried that she would be shock and it would affect her
condition.
5. ACT AS PATIENT ADVOCATE VERSUS MAINTAINING RELATIONSHIPS WITH
THE HEALTH TEAM
Patient was poor and could not afford the prescribed drug. I was in a difficult situation
whether I administered the drug or not. If I didn't administer it, it was doctor's order
and he might be angry with me and it would produce bad relationship with him. I
needed to talk to doctor about this and asked him to prescribe another drug that
could be afforded by the patient, but I was afraid
6. Deligatioan
Miss Corbin, RN, work on surgiucal floor. She has just assisted in the transfer of Mr.
Hudson (patient) to his room from the postanesthesia unit after surgery and notice that
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he was resting comfortably. Miss Corbin sees a nurse colleague (X) drawing up a pain
medication. The nurse colleagues returns to the medicine room 10 minutes later with
empty syringe. Miss Corbin asks, Who needed pain medication? Mr. Hudson, the
colleagues (X) replies. He was in pain after surgery. Confused, Miss Corbin checks Mr.
Hudsons (Patients) room and learns from his wife that she has not asked for or
received pain medication. What should Nurse do now?
Bandman & Bandman (1997: 410)
7. Autonomy dan Negligence
SUSTER TIDUR, BAYI TEWAS!
Pasien (Heston dan Ashdiane-suami) melaporkan ke polisi, krn suster melarang
permintaan pasien utk dilakukan Caeser. Jam 17.00 ketuban pecah, tetapi tetap
dianggap biasa oleh suster. Jam 19.00 pasien merasa mulas yg amat sangat.
Permintaan suaminya (Heston) agar istrinya ditolak oleh suster. Pukul 02.00 (23/9/04)
pasien merasakan ada sesuatu yg mengalir di bagian bawah perutnya. Diapun segera
membangunkan perawat yg sedang tidur nyenyak. 1 jam kemudian, begitu dokter
datang langsung dibawa ke ruang operasi. Namun, bayi yg dilahirkan dlm keadaan
kritis. Jam 17.00 bayi meninggal.
8. Autonomy & Informed Concent
Eleanor Gift,age 68 years, is schedule for triple bypass surgery. Martha Blake, RN, is the
nurse doing her preoperative teaching the evening before the procedure is scheduled. It
is apparent to Miss Bake that Mrs. Gift doesnot want to have surgery. She express great
apprehension about procedure and generally feells quite negative about the outcome.
The surgeon, however, has convinced Mrs. Gist and her family that she must undergo
the surgery to survive. Although far from comfortable with situation, Mrs. Gift is resigned
to undergo the impending surgery in the morning. What is the nurses responsibility in
the situation?
CONTOH PENERAPAN EDM PADA KASUS NO. 8
TAHAP 1: CLARIFY ETHICAL DILLEMA
Many questions are not answered in this case study. Clearly the decision regarding
having surgery should be made by the one most affected (i.e. Mrs. Gift). Others are
affected by her decision, however. There is no information given about her family or how
involeved they are in her health care. Other care givers also may play a significance
role. The ethical principle of autonomy is important in this scenario. Unfortunately, time
is quite short because Mrs. Gifts surgery is scheduled in the morning.
TAHAP2: GATHERING ADDITIONAL DATA
The nurse need to know information from Mrs. Gifts medical history related to the
extent of her cardiovascular disease. It is also important to know what she has been told
about the surgery and her need for it. Has she ben given the necessary information to
allow her to make an information decision?
We can also gather the data from ansewering questions on 5W and 1 H
TAHAP3: IDENTIFY OPTION
The following nursing actions are options for the nurse in this situation:

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Continue preoperative teaching under the assumption that surgery will take place
as schedule
Continue preoperative teaching and let the increased knowledge b e used as an
additional tool to assist Mrs, Gift in decicion making
Etc
Principelly, the options can be divided into 3 options possibles
1. should be attack
2. can be avoided
3. compromise

Suitability

Feasibility

Flexibility

Total

Alternative A

Alternative B

Alternative C

Alternative D

Alternative

Rate each alternative on scale of 1 3 for its

Suitability: whether the alternative is ethical or pratical. Is it appropriate in

scale or importance? An adequate response? Too extreme?
Feasibility: how many resources will be needed to solve the problem, how
likely will it solve the problem, How likely will it solve the problem?
Flexibility: ability to respond to unintended consequences, or opennes to new
possibilities?

TAHAP 4: MAKE A DECISION

Choose one of the options. In this situation, it seems most appropriate the explore Mrs.
Gift concerns and feelings about the surgery. It is important to determine if patients truly
feels the surgery is in the best interest and if she has made an autonomous decision.

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TAHAP 5: IMPLEMENTATION
Once a decision is made, it is important to implement the action. In this situation, the
nurse decides to explore patients concerns and determine if an autonomous decisions
was made by the patient.
TAHAP6: EVALUATION
The step is important, even though it may seem obvious. It is necessary to evaluate the
implications of the decision that was made. The nurse must determine if the action
implemented accomplished what was intended. Evidence that the intervention was
succesfull would include a decrease in Mrs. Gifts anxiety level and negative feelings
about the probable outcome of the surgery.

DAFTAR PUSTAKA
Bandman, LE & Bandman B. 1995. Nursing Ethics Through the Life Span. 3rd ed.
Norwalk: Appleton & Lange.
Chitty, KK. 1997. Professional Nursing. Concepts and Challenges. 2nd ed. Philadelphia:
W.B. Saunders Co.
Edge RS & Groves JR. 2004. Ethics of Health Care. A guide for Clinical Practice.
2nd.ed. Philadelphia: Delmar Publishers.
Nursalam. 2008. Proses dan Doukumentasi Keperawatan. Edisi 2. Jakarta: Salemba
Medika

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