LEGAL ISSUES IN NURSING PRACTICE

I. INTRODUCTION

The role of nurses and professional nursing has expanded rapidly within the
past ten years to include expertise specialization autonomy and accountability, both
from a legal and ethical prospective. This empasion has forced new concern among
nurses and a heightened awareness of the interaction of legal and ethical principles.

This term law is derived from its tentoric root ‘lag’ which means something which
lies fixed or events. In English it means something which is uniform. The word ‘law’
is employed in the modern usage in a variety of ways.

II. LEGAL ISSUES

Many legal issues affect the licensed practical/Vocational nurse and influence the
level of care delivered to the patient. Statutory and common law both play important
roles in defining the rights and responsibilities of the patient and nursing professionals.

1. Malpractice

The nurse can be held legally liable for acts of commission (doing an act) or
omission (not doing an act). Malpractice (professional negligence) is one legal action
that a nurse may be charged with for failing to meet the standards of care.

The following elements must be present for a charge of malpractice.

1. Duty exists: The nurse/patient relationships establish a duty.

2. Breach of the duty: Failure to perform the duty in a reasonable, prudent manner.

3. Harm occurs: This does not have to be physical injury.

4. The breach of duty: Was the proximate cause of the harm – without the breach the
harm would not have happened.

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 2. Patient Rights

 Patients have expectations regarding the health care services they receive.
 In 1972 the American hospital Association (AHA) developed a patient’s Bill of
Rights.
 In 1980 the Mental Health patients Bill of Rights and the pregnant patients Bill of
Rights were adopted into law.
 The patient self Determination Act (included in the omnibus Budget
Reconsiciliation Act of 1990, 42 U.S.C and 1935 cc (a) (1)} was enacted to regulate
any institution receiving federal funding.
 Among the rights that health care institutions must provide to their patients are the
right to have occurs to health care without any prejudice; to be treated with respect and
dignity at all times; to privacy and confidentiality, to personal safety while in the
institution; to complete information about their condition and treatment; and to give or
not give consent for care.
 Some of the responsibilities that patients have to the health care institution are to
provide accurate information about themselves; to give information regarding their
known conditions and to participate to indecision making regarding treatment/care.
3. Informed Consent

 The patient Bill of rights includes the patient’s right to make decisions regarding
his or her health care.
 Informed consent doctrine is a persons agreement to allow a particular treatment
based on full disclosure of the facts needed to make an intelligent (informed) decision.
 Before any invasive treatment or procedure an be performed, the patients needs to
be aware of the benefits of the treatment, the risks involved, any alternative treatments,
and the consequences of refusing the treatment or procedure.
 The patient has the right to choose to accept or reject the proposed care but only
after understanding fully what is being proposed.

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 Procedures must be explained in non-technical terms and in a language the patient
can understand.
4. Confidentiality

 The licensed practical / Vocational nurse has a duty to protect information about a
patient no matter how that information is received.
 The information received about a patient must be guarded and occurs to their
information restricted to only those health care members who have a legitimate need to
know.
 Failure to maintain patient confidentiality gives rise to legal liability and legal
remedies exists to address confidentiality breaches.
 Whether on duty or off duty, the nurse can not breach a patient’s confidence.
 The duty does not end when the patients is discharged.
 If the nurse has questions regarding the disclosure of patient information, the nurse
should follow the policies of the employing institution.
5. Medical Records

 Laws govern the collection, maintenance, and disclosure of medical record

information.
 Each health care instititution will also have policies and procedures regarding
the patients medical record.
 Medical records are not public documents, and the information they contain is
to be guarded.
 Breaches in the confidentiality of information kept I the patients medical
record also gives rise to legal liability.
6. Invasion of privacy

 The legal concept of invasion of privacy involves a person’s right to be left

alone and go unnoticed if he chooses.

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 When a patient consents to be cared for by a nurse, the patient does not waive
the right to privacy.
 Exposing the patients body parts unnecessarily, discussing the patient
inappropriately, or disclosing information about the patient may result in legal
liability.
 Using may authorized patient information (name, photograph, specific facts
regarding an illness and so on) is a violation of the patients legal rights. The nurse
needs to safeguard the patients right to privacy at all times.
7. Reporting Abuse

 There are exceptions to the right to privacy. The law prescribes when a health care
professional must report certain information to the appropriate to the appropriate
authorities.
 When man-dated to report information (eg. Certain communicable diseases or
gunshot wounds), the health care professional is protected from liability when acting
in good faith.
 The nurse must be alert for the signs of abuse, especially in high-risk populations
such as children and older adults.
 In response to the enormous problem of child abuse, the federal child abuse
prevention Treatment Act of 1973 was enacted.
 The child Abuse Amendments were enacted in 1984 in an attempt to protect the
rights of these handicapped infants.
 These regulations made any institutions receiving federal funds legally responsible
to investigate the withholding of medical treatment to an infant.
8. Physician – assisted Suicide

 The issues of physician – assisted suicide (PAS) has received much media
attention with the public actions of Dr. Kevorkian, PAS, a form of active euthanasia,
involves the physician taking an active role on helping to end a patients life.

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 Through the legal status of PAS remains unclear, ethical issues directly affect
health care professionals.
III. LEGAL ROLE OF THE NURSE

Professional nursing practice is not determined by a simplistic adherence

to patient’s rights. Rather it emerges from interplay between the rights of patients and
the legal role of the nurse, and her concern for quality psychiatric nursing. There are-
three roles that the psychiatric nurse moves in and out in the process of completing
her/ his professional and personal responsibilities. These are: the role of provider of
services, employer or contractor of service and private citizen. These roles are played
simultaneously and each role has attendant rights and responsibility.

1. ACCOUNTABILITY :
Meaning of Accountability: Accountability is the process that mandates that
individual is answerable for their actions and have an obligation to act. The person or
position accountable for a task is responsible for insuring that it is completed on-time
and in a manner which meets all expectations for it. The Accountable (A) person or
position does not have to physically do the task. Accountability should be focused on
the "Responsible" person whenever possible. Accountability must be assigned to each
task.
The nursing profession is accountable for establishing and maintaining standards that
promote safe, effective care. Accountability is one of the distinguishing characteristics
of a profession. The professional nurse is accountable for several domains,
professional organization legal and ethical.
Professional accountability: professional nurse are held accountable by the public to
possess the necessary knowledge and skills to render safe nursing care and to use
proper judgment in the provision of nursing services. The profession is held
accountable by the public to ensure that only qualified individuals are granted the right
to practice and that those who fail, to uphold the professional standards are denied the
future right to practice.

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 Professional accountability within nursing is fostered through the mechanism by which
the nurses obtain the right to practice.
Legislative accountability: for nurses to be recognized as professional nursing must
have legislation that clearly defines the role and scope of nursing practice. The legal
regulation is the process by which the state attests to the public that the individual
licensed to be practiced at least minimally competent to do so.
Organizational accountability: organization is the means by which the members of a
profession, such as nursing, join together to promote and protect the profession as a
valuable service to society. Professional regulation is the process by which nursing
ensures that the members act in the public interest by providing a unique service that
society has entrusted to them.
Individual accountability: professional nurses must know and understand the rules
and regulation of nursing board in which they are licensed so that they can be active
participant in the development of regulation affecting their practice.

2. RESPONSIBILITIES:
RESPONSIBILITY OF APPOINTING AND ASSIGNING
Nursing responsibilities are expected to be aware of legal restrictions affecting
personnel appointment and assignment. A manager who depart from agencies hiring
policies can be held negligent if she or he appoints an employee, without appropriate
screening and that employee later injures a patient. The nurse administrators have
responsibility for staffing and supervising nursing units to ensure safe, effective patient
care. Therefore they have the authority to temporarily reassign a nursing employee
from one unit to another to compensate for emergency staff shortages. In shifting an
employee to compensate for personnel shortage, a supervisor or manager must take
into consideration the nurse’s capability to discharge duties of the temporary position.
In floating nurses to an intensive care unit to compensate for understaffing, the

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manager should reassign only those nurses whose education and experience have
prepared them to perform all of the nursing functions common to an intensive care
unit.
Each nurse has legal responsibility to make full disclosure of her or his
background knowledge and skills and notify the nurse manager when given an
assignment for which she or he is not qualified. The manager is also obliged to adjust
the amount and type of supervision to fit and employees level of maturity and
experience. Less experienced or less skilled employees need more professional support
and advice from the manager.
RESPONSIBILITY IN QUALITY CONTROL
The nursing administrator and the authority of the agency at all levels have a legal
obligation to ensure nursing care quality. A nurse manager’s legal responsibility for
quality control of nursing services imposes a duty to observe report and correct the
incompetence of any patient care are provider. Usually the head nurse or ward in
charge is responsible for quality of patient care given by all personnel including
medical on the nursing unit, whether or not these individuals have responsibility to the
head nurse.
RESPONSIBILITY FOR EQUIPMENT
To protect patients and employees from injury, a nurse manager must ensure that
all patient care equipments is promptly repaired or replaced. He/ she must ensure that
nursing personnel know how to operate sophisticated equipment, so that he/ she is
expected to provide instructions in proper care equipment, even then, there is a service
contract providing for maintenance by an outside contractor. Nurse also has duty to
refuse to use equipment known to be faulty or that was not designed for use in the
situation where it was ordered.
RESPONSIBILITY FOR OBSERVATION AND REPORTING
Nursing personnel have more frequent and prolonged patient contact than other
care giver. Nurses are trained to detect significant symptoms and reactions.
Consequently nurses have a legal duty to observe patients frequently and report

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findings that have diagnostic or treatment value for the patient’s physician and other
members of the patient’s treatment team. The nurse is expected to observe a patient
more closely when his or her condition implies increased health risk. Infants, children,
aged, disoriented psychiatric and critically ill patients require more frequent
observation than other patients with no evidence of impending respiratory or cardiac
emergency.
The nurse has a duty to record and report observation of a patient’s condition
promptly, so that the physician can base treatment, decision son up to date information
about the patients health needs. When the patient’s condition deteriorates to the point
that immediate action is needed to save life or limb, the nurse must report observations
of the patients worsening conditions to the concerned doctor in person or any means.
The nurse has a duty to report improper medical care through appropriate channels in
order to protect patients from Doctors negligence.

RESPONSIBILITY TO PROTECT PUBLIC

The nurse has a legal duty to protect the public from injury by dangerous patients.
Each nurse manager or administrator should ensure that the agency in which she or he
is employed has a policy describing the procedure to be followed when a patient with
violent tendencies or who threaten violence to others is discharged or escapes from the
health care agency. The manager must ensure that nursing personnel follow the
procedures to alert community members to the presence of a potentially dangerous
patient in their midst.
RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

Nurses have legal responsibility for accurately reporting and recording

patient’s conditions, treatments and responses to care. The medical record is a written r
computerized account of a patient’s illness and treatment that includes information
submitted by all members of the patients health care team. The medical record is an

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information source document that should be used to plan care, evaluate care, allocate
costs, educate personnel, research care measure and substantiate legal claim.

Patient’s medical record is essential to proper care and it is the property of the
healthcare agency. However, patient has a property right to information contained in
the report; the patient has right to inspect and copy the record after being discharged.
However, it is not advisable to allow a patient to review his or her medical record
without medical supervision and explanation, because patient is likely to
misunderstand certain record notations.
Failure to record significant patient information in the medical record makes a nurse
guilty of negligence when the patient is injured because of physicians / surgeons
ignorance of significant information almost medical history, signs and symptoms. The
medical record must be accurate to provide a sound basis for care planning. Therefore,
errors in nurses charting must be corrected promptly in a manner that leaves no doubt
about the facts.
Every health care agency should have a policy and protocol that direct that an
erroneous chart entry be crossed through, labelled, or erroneous, signed by the
employee who corrects the error and retained in the patients record. Correct
information should then be documented to replace the erroneous data. Pages of the
record that contain erroneous and corrected entries should never be destroyed. Nurses
who conspire with Doctors and others to falsify patient record for purposes of
concealing a criminal violation may be found criminally liable.

All health personnel require to report certain incidences to concerned authorities such
as child abuse, ophthalmia neonatorum- infant phenylketonuria, communicable
diseases, births out of wedlock, gunshot wound, suicide, rape and use of unprescribed
narcotics. In reporting information about criminal acts obtained during patient care, the
Nurse must reveal such information only to the police, because it is considered a
privileged communication.

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RESPONSIBILITY FOR DEATH AND DYING

There are many issues surround the events of death. Death occurs when there is an
absence of brain function, despite functions of other body organs. However, Nurses
must be aware of legal function of death because they must document all events, that
when the patient is in their care. Sometime there will be issues of euthanasia, either
active or passive. Active euthanasia is defined as intentional homicide, e.g.
intentionally administering a lethal dose of morphine to a patient to cause death. An
example of passive euthanasia includes, removing breathing support or withholding
blood transfusion from a terminally ill patient with irreversible brain damage, may
raises legal questions.

In addition, documenting all events surrounding deaths, Nurses have other specific
legal duties which include, treat a deceased person with dignity and obtaining consent
from an autopsy from the decedent or a close family member. A competent adult can
legally give consent to denote specific organs and nurses may serve as a witness to this
decision.
Nurse as a provider of services: all psychiatric professional have legally defined
duties of care and are responsible for their own work. If these duties are violated
‘malpractice’ exists. Malpractice involves the failure of a professional person to give
the kind of proper and competent care that is given by member of his profession in the
community resulting in harm to the patient. Most malpractice claims are filed under
the law of negligent tort. A tort is a civil wrong for which the injured party is entitled
to compensation.

Nurse as an employee: To practice nursing legally, a nurse must possess a valid

and current licence from the appropriate agency in the state where the nurse employed.
Licensure is the process by which a competent authority grants permission for
qualified individual to offer her/his skills and knowledge to the public in a particular
jurisdiction where such practice would be unlawful without a licence.

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 Licensure laws may be permissive or mandatory. However, there is a pronounced
trend towards compulsory licensure of professional and practical nurses. Where
licensure is mandatory unlicensed individuals are prohibited from practicing the
occupation. When licensure is voluntary, unlicensed individual are denied use of
protected title but are not prevented from performing work similar to that of persons
licensed to use the protected title. The primary purpose of a licensure law is to protect
public from injury by unqualified practitioners through enforcement of minimum
practice standards.

Nurse as a citizen: this role is particularly significant because all other roles, rights
responsibilities and privileges are awarded because of the inherent right of citizenship.
In our form of democratic Government these rights are inherent, civil rights, property
rights, right to protection from harm, right to a good name and right to due process.
These rights form the foundation for the extension of other legal relationships of the
nurse.

PATIENT CARE ISSUES, MANAGEMENT ISSUES, EMPLOYMENT

ISSUES AND MEDICO LEGAL ISSUES

I. INTRODUCTION

Nursing is defined as providing care to the healthy or sick individuals for

preventive, promotive, curative and rehabilitative needs. The Consumers are patients
with complex needs. With increased awareness of health care, health care facilities and
consumer protection Act, patients/clients are getting awareness about their rights.
Nurses also have now the expanded role, with the result the legal responsibility is
increased. Hence, it is important for nursing personnel working in hospital, community
and educational field to develop understanding of Legal and Ethical issues of Nursing.

The law requires nurses to provide safe and competent care. This care is defined
as the level of care that would be rendered by a comparable nurse in a similar

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 circumstance and is referred to as a standard of care. Every employment environment
for nurses should have standards of care. It is your responsibility to review the
standards and follow them. Reviewing standards of care is an excellent way to
determine if you are interested in working for an organization. If for any reason you do
not think the standards are high enough for quality care to be given, leave the situation
immediately.When you do not follow standards of care, you are probably committing a
criminal or civil crime. The situations discussed in this section are common problems
for nurses. You must be aware of them and thoroughly understand them.

Issues need deliberations and common consensus. They need to be reviewed

periodically. Issues which seem not feasible, and ideal, may become practice with the
change of time. Some of these issues threaten nurses who do not keep up with the
changing development. These issues are base for the future trends in care.

MEANING OF LEGAL ISSUES

It is a standard or rules of conduct established and inforced by the government.

These are intended to protect the public.

II. PATIENT CARE ISSUES

Nursing covers a wide range of disciplines and health-care issues that are
always changing and at the forefront of what guides this career path. Issues such as
health-care reform, nursing shortages, low salaries and ethics are some of the issues
being faced. With nursing being an integral part of hospitals, nursing homes, home
health agencies and colleges, the discipline has to keep current of changing policies
and be prepared to address whatever may arise.

a. Nursing Shortage
The nursing shortage is a major issue facing the biggest licensed profession
in the health-care system. This shortage will affect health care more each day, as it
appears not much is being done to stop it. Many emergency rooms have longer wait
times due to less nursing staff, and hospital floors are feeling the effects as well. This
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 is affecting patient care because the number of patients to one nurse is increasing,
therefore decreasing the quality of care. This shortage is being felt in hospitals, nursing
homes and home-health agencies. Nursing has been lobbying for patients by seeking
legislation to help with the nursing shortage and with funding for nursing schools.

b. Health-Care Reform

Nurses have always been involved with health-care reform as advocates for
patients. The American Nursing Association (ANA) has been working to have the
voice of nurses heard. Nurses are in support of a public plan, so Americans who are
underinsured or uninsured will have access to affordable, quality health insurance. The
ANA has taken the stand that health care is not a privilege but a right. It is lobbying
for a reduction in cost and an end to high out-of-pocket costs for services, as well as
ending discrimination pertaining to pre-existing conditions.

c. Low salaries
d. Standard Care
 State Nurse Practice Act
 ANA-Standards of Clinical Nursing Practice
 National Association of School Nurses (NASN)
 School policy and protocols
III. MANAGEMENT ISSUES
Nurses working in doctors' offices and hospitals have a difficult job caring
for patients and meeting the needs of both coworkers and superiors within the
institution. Nurse Managers who work in the medical professional also have a complex
and challenging role. It is a considerable challenge to meet the needs of the
organization, the needs of patients, and the needs of the nurse employees.

a. Turnover
Maintaining adequate staffing levels is a major issue in nursing management.
Representatives working in nurse management and leadership are often faced with

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 the responsibility of controlling turnover rates. Nurses faced with long work hours for
relatively little pay have few motivations to remain in one position and often seek
employment opportunities at competing hospitals and neighboring clinics.

b. Funding
Lack of funding is an issue for many nurse managers who seek to provide sufficient
compensation to existing nurses as well as offer suitable compensation in an attempt to
recruit new nursing professionals for hire. An underfunded institution cannot attract
and provide for the right professionals, and funding inadequacies can also become a
detriment to the level of training provided to medical staff, in addition to the needs for
medical equipment and supplies. When the medical institution's quality of staff and
training standards must be lowered because of budgetary concerns, the overall level of
patient care is unavoidably reduced.

c. Workload
Individual nurse manager workload and overall medical workload are issues in
leadership. The medical profession is one that never sleeps and has an almost constant
need for qualified professionals both in hiring and scheduling. Not only do nurse
professionals work long hours and many days per week, but nurse managers and
leaders are also faced with an ever-increasing workload. Dealing with patient
concerns, providing training and support to nurses, and acting as a liaison between
doctors, nurses and medical administration members can be taxing and stressful. Many
nurses are unwilling to enter into the nurse management field because of the added
stress and responsibility. When you add to all that the secondary stresses of budgetary
cutbacks and fewer nurse leadership roles, it means that existing nurse managers are
faced with enormous challenges when it comes to balancing their leadership functions.

d. Issues regarding malpractice in nursing management

Issues of delegation and supervision

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 The failure to delegate and supervise within acceptable standards of professional
practice.
Issues related to staffing

 Inadequate accreditation standards- adequate number of staff members in a time of

advancing patient activity and limited resources.
 Inadequate staffing, i.e. short staffing.
 Floating staff from unit to unit.
e. Ethics
Nurses are held to a high standard of ethics when it comes to patients, co-workers and
themselves. They provide care, promote human rights and values, and help meet the
needs of the less fortunate and vulnerable. A major ethical goal is to also keep patients'
information confidential, and this includes not discussing patients in public places.
Another ethical issue is protecting patients from negligent co-workers who may
endanger them. The individual nurse must not endanger the patient and has to be
accountable to the standards of the field.

f. Effect
Effects of reform, shortages, ethics and salaries are issues that keep nurses constantly
thinking, growing and changing.

Nursing instructors make far less money than nurses in the clinical setting. They also
make less than other educators in different fields. In order for nursing to succeed, there
needs to be qualified candidates educated, but with these low salaries nurses are not
flocking to this career path. Without these types of nurses being adequately filled then
qualified candidates will not have the opportunity to be taught. These salaries need to
be increased, and colleges and universities need to see the value in these instructors.

g. Issues in Nursing Curriculum Development

 Where are we now?

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 As nursing faculty we need to answer the question and analyze the present situation
whether or not we are on the road to relevant, which means the validation of
curriculum or judgemental process in which an attempts is to be made to ascribe a
degree of worth or value to a curriculum in the context of professional education and
preparation of participants for their professional role.

Walker describes five types of validation

 Academic validation
 Professional validation
 Economic validation
 Institutional validation
 Performance validation
Then identify the strengths of present system/situation before starting the program.

 Where we want to go?

This deals with the thinking and aspiration for future. Faculty must think whether the
educational program what is designed will help to meet the expectations of
individuals, families and communities in accordance far with the developed countries
or not.

 What we want to achieve?

Nurse educators must be able to analyze and think critically that we are preparing the
students with the adequate skills to perform their expected roles in all the three
domains of professional tasks such as practical, communication and intellectual skills
according to the institutional goals and educational objectives.

The three types of skills to be achieved:-

 Domain of attitudes (communication skills)

 For example, feelings, values and interpersonal relationships
 Domain of practical skills (imitation control and automatism)

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 Domain of intellectual skills(knowledge and recall of facts)
 For example, Interpretation of data and problem solving.
 How can we achieve?
The faculty must think the ways by which the curriculum can be developed to which is
relevant to meet the needs of the country.

h. Collaboration issues
The nursing profession is faced with increasingly complex health care issues driven by
technological and medical advancements an ageing population, increased numbers of
people living with chronic disease, and spiraling costs. Collaborative partnerships
between educational institutions and service agencies have been viewed as one way to
provide research which ensures an evolving health care system with comprehensive
and coordinated services that are evidence- based, cost – effective and improve health
care outcomes. These partnerships also ensure the continuing development of the
professional expertise necessary to meet these challenges.

IV. EMPLOYMENT ISSUES

a. Issues related to Nursing Shortage
The nursing shortage is another international event. Why is there a nursing
shortage? There are many opinions regarding that question. I have been a nurse long
enough to recognize that nursing shortages wax and wane. This shortage is more
noticeable, however and it is lasting longer. The nurse shortage itself is a contributing
factor because the shortage creates staffing problems, mandatory overtime, and
constant calls for additional shift work.

National nursing organizations are making strong efforts at stopping the shortage by
mandating better nurse- to-patient ratios, eliminating mandatory overtime, and
increasing salaries and benefits for nurses.

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b. Issues in Nurse Migration
Nurse migration has attracted a great deal of political as well as media
attention in recent years. The rights to healthcare as well as workers’ rights are
paramount to understanding the interests of health sector stakeholders, including the
consumer or patient, the government or employer, and the worker or health
professional. In this section a discussion on the right to work and the right to practice
is, by necessity, followed by a warning that cases of exploitation and discrimination
often occur when dealing with a vulnerable migrant population. Additionally,
international migration policy issues addressing the somewhat conflicting sets of
stakeholders' rights are presented, and ethical questions related to nurse migration are
noted.
c. The Right to Work and the Right to Practice
Professionally active nurses are important players in an increasingly
competitive and global labor market. Unable to meet domestic need and demand,
many industrialized countries are looking abroad for a solution to their workforce
shortages; the magnitude of current international recruitment is unprecedented (ICN,
2005).
For nurses to practice their profession internationally, they need to meet
both professional standards and migration criteria. The right to practice, e.g., to hold a
license or registration, a professional criteria, and the right to work, e.g. to hold a work
permit, a migration criteria, are sometimes linked. Yet they often require a different set
of procedures with a distinct set of competent authorities.
In the interest of public safety, nurses' qualifications must be screened in a
systematic way to ensure they meet the minimum professional standards of the country
where they are to deliver care. This may be in the form of a paper screen, for example
automatic recognition of qualifications received from a given country or school; tests,
such as the NCLEX licensing exam; supervised clinical practice, as seen in an
adaptation period; and/or successful completion of an orientation course/program.

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 Language is a crucial vehicle for the vital communication needed both
between the patient and care provider, and also between members of the health team. It
is not surprising that in many countries, a nurse's right to practice is limited if the
foreign-educated nurse's language skills do not support safe care practices. Passing
specific language tests are required in certain countries. In others, the employer is held
responsible for ascertaining the language competence of the employees/health
professionals. Clearly, history has demonstrated a tendency for migrant flows to be the
strongest between source and destination countries that share a common language
(Kingma, 2006). For example, nurses wishing to migrate from Morocco will tend to go
to France while nurses from Ghana will be attracted by the United Kingdom. As the
pools of nurses willing to migrate change, and as language competency becomes a
professional advancement requirement, language barriers may prove to be less of a
constraint, and we may see Chinese nurses working in Ireland and Korean nurses
going to the US.
Foreign nurses also need to meet national security and immigration criteria
in-order-to enter the country and to stay on a permanent or temporary basis, with or
without access to employment. There is no doubt that nurse mobility will be affected
by national security concerns and decisions on how fluid the borders will be
maintained. For example a tightening of border restrictions after terrorism attacks or
the opening of borders with new economic agreements, such as the expansion of the
European Union, will continue to influence nurse migration patterns.
d. Exploitation and Discrimination
One of the most serious problems migrant nurses encounter in their new
community and workplace is that of racism and its resulting discrimination (Chandra
& amp; Willis, 2005). Incidents are, however, often hidden by a blanket of silence and
therefore difficult to quantify (Kingma, 1999). Migrant nurses are frequent victims of
poorly enforced equal opportunity policies and pervasive double standards. Some
migrant nurses are experiencing dramatic situations on the job where colleagues
purposefully misunderstand, undermine their professional skills, refuse to help, and

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 sometimes bully them, thus increasing their sense of isolation (Allan & amp; Larsen,
2003; Hawthorne, 2001; Kingma, 2006). If we recognize that international migration
will continue and probably increase in coming years, the protection of workers is a
priority issue and should be safeguarded in all policies and practices that affect migrant
health professionals.
e. Essential Terms and Conditions in an Employment contract
An employment relationship has traditionally been governed by the terms
and conditions of the employment contract. Previously, the employer retained sole
control in respect of the terms and conditions of employment to be incorporated into
the employment contract. However, over the years there has been an increase in the
implied terms and conditions which are also read into the contract. Additionally, then
there are the statutory terms and conditions which also apply. A badly drafted
employment contract which does not correctly express the intentions of the employer
on such matters as working hours, prolonged illness, bonus payments, usage of office
computer facilities, transfers, retirement age, confidentiality, conflict of interest,
disciplinary action and imposition of punishment, etc or the omission to mention some
of these items in an employment contract can give rise to serious consequences for
employers. This talk will focus on what are considered as essential terms and
conditions which employers must incorporate into an employment contract and the
consequences of failure to do so.

f. Unsatisfactory work performance and termination of employment

The Courts have time and again reiterated that employees enjoy security of
tenure of employment. The maxim "easy to hire difficult to fire" is a truism even in the
case of probationers. No employer having hired a person at considerable cost and
having exposed the person to training, formal or otherwise, will want to terminate the
person. However, when an employee has an attitude problem or whose work
performance is not up to the expectations he cannot be terminated by the employer
simply by invoking the termination clause in the employment contract. The employer

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 has to follow certain rules and procedures and only at the end of it can he terminate the
services of a non-performing employee. Even then, there are no iron clad assurances
that the termination will not be challenged by the employee at the Industrial Court.
How does an employer ensure that he minimizes the risk of being challenged in Court
over a termination of employment due to unsatisfactory work performance? This talk
will attempt to take you out of the labyrinth.
g. Misconduct and imposition of punishment
It has long been held that the employer has the inherent right to discipline
his workers. Should misconduct be committed, the employer after a proper inquiry has
been instituted can impose a suitable punishment, including dismissal if the offence
committed was of a serious nature. The decision on the type of punishment to be
imposed is under all circumstances a subjective one. The Courts will interfere if,
among others, the action taken by the management was perverse, baseless or
unnecessarily harsh or was not just or fair. There have been occasions where
employers have imposed the punishment of dismissal for misconduct which they have
assessed as serious but these cases have been reviewed by the Industrial Court and the
decision of the employer substituted. Given that imposition of punishment is a
subjective matter, what factors or criteria should an employer apply in determining
appropriate punishment for misconduct committed in employment. This talk, among
others, will examine some of the issues to be taken into account.

i. Sexual harassment at the workplace

Sometime ago this subject matter received a great deal of attention
especially with the launching of the Code of Practice on the Prevention and
Eradication of Sexual Harassment at the Workplace by the Ministry of Human
Resources. However, the response to the adoption of the Code by employers was not
encouraging. Some NGO's have called for the introduction of statutory measures to
deal with the problem. Some recent judicial pronouncements appear to make it
difficult to prove sexual harassment had indeed taken place. Regardless of all these

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 what is the proper attitude that ought to be taken by employers in this matter. Do
employers have a legal responsibility to safeguard their employees from sexual
harassment at the workplace? To what extent can employers dictate without being
accused of encroachment into a person's private life and social interaction. How is an
employer to deal with sexual harassment cases and what standard of proof is called for
when usually harassments are .private and confidential incidents'.

j. Renewal of nursing registration

So that registration office is updated with nurses in practice. Of course re-
registration may qualify its periodicity and qualifications of nurses e.g. clinical
experience, attendance at continuing education etc.

k. Diploma vs degree in nursing for registration to practice nursing

This issue need indepth study of merits and demerits as well as its
feasibility before it could come on the surface.

l. Specialization in clinical area

It could be either through clinical experience or education. Specialization in
cure and specialized care required for patients demand that nurses be highly skilled in
the unit. Generalization of care seems remote and unacceptable for patients under
specialized treatment.

m. Nursing care standards

Standards must be laid down and followed so that clients understand the
quality of care expected from the nurses.

V. MEDICO LEGAL ISSUES

Nurses face legal issues daily. Those issues may be in connection to negligence,
administering medication and advocating for the patient. The Nurse Practice Act lists
all of the duties and role of a nurse, except the legal and ethical issues. If these duties
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 and regulations are not followed, the nurse is at risk of losing his license and facing a
malpractice suit.

i. Legal Issues Specific to Nursing

a. Duty to seek Medical Care for the patient
It is the legal duty of the nurse to ensure that every patient receives safe
and competent care. The nurse cannot guarantee the patient will receive medical care
that the nurse be a strong advocate for the patient and use every resource to ensure
medical care is received. If you determine that a patient in any setting needs medical
care, and you do not do everything within your power to obtain that care for the
patient, you have breached your duty as a nurse.

b. Confidentiality
It is a privilege to care for other people. At times, your patients will relate
to you in a personal way. One of the outcomes of your relationship is that you may be
told information of a personal nature.in addition to what a patient may share with you,
you have access to the person’s hospital records. The law requires you to treat all such
information with strict confidentiality. This is also an ethical issue. Unless a patient
has told you something that indicates danger to self or others, you are bound by legal
and ethical principles to keep that information confidential.

c. Permission to treat
When people are admitted to hospitals, nursing homes, and home health
services, they sign a document that gives the personnel in the organization permission
to treat them. Every time the nurse provides nursing care to person, however,
permission must be obtained. The courts have ruled that people are expected to have
some understanding of basic care, which means the nurse should explain briefly what
he or she is about to do. The concept of permission to treat should be in your mind as
you give nursing care. For example, most personnel who pass food trays automatically
ask, “Are you ready to go for a walk now? These automatic questions actually are

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permission to treat questions. When you are giving medication, you may say, “Here
are your pills,” Here is the new medication the doctor ordered for you.” If the patient
takes the medication, he or she has given you permission to treat.

d. Informed consent
The concept of permission to treat is closely tied to the concept of informed
consent. The law states the persons receiving health care must give permission to treat
based on informed consent. The principle of informed consent states that the person
receiving the treatment fully understands the possible outcomes, alternatives to
treatment, and all possible consequences.

The physician is responsible for obtaining informed consent for medical

procedures, such as surgery, whereas the nurse is responsible for obtaining informed
consent for nursing procedures. Each institution has forms for informed consent for
complex or serious procedures, such as surgery, chemotherapy, or electroshock
therapy. Check with your institution and review the forms available for informed
consent.

Surgical procedures commonly require informed consent. Although the law

states that either verbal or written consent is acceptable, most institutions require
written consent because it is the most legally binding. It is the physician’s
responsibility to give the surgical patient the information necessary to meet the
requirements for informed consent. It often is the responsibility of the nurse to get the
surgical consent from signed.

e. Advance Directives
Although the Patient Self – Determination Act was passed by the U.S.
Congress in 1990, it was not implemented until 1992. The act states that all the health
care institutions are required to give clients or patients an opportunity to determine
what lifesaving measures or life-prolonging actions they want implemented. This
requirement applies to all hospitals, long term care facilities, and home health agencies

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 and is to be done at the time of admission. The institution is required to give adequate
information to the person and assist in completing any forms. In most situations, the
nurse is responsible for educating patients if there is not enough information to make
an informed decision.

The purpose of advanced directives is to give the person an opportunity to

make decisions regarding healthcare before an illness or a need for treatment that
would prohibit making such critical decisions.

f. Negligence
The law requires nurses to provide safe and competent care. The measure of
safe and competent care is the standards of care. A standard of care is the level of care
that would be given by a comparable nurse in a similar situation. Negligence occurs
when a person fails to perform according to the standards of care or as a reasonably
prudent person would perform in the same situation.

It is the responsibility of the nurse to monitor the patient. If a patient calls

for a nurse to come and assist him in going to the restroom for example, the nurse is to
assist, or if the is busy with another patient, have another nurse assist the patient.
Ignoring the patient or responding after a lengthy delay could be considered
negligence, and if the patient is hurt from trying to move himself, the nurse could face
legal suits. Also, it could be considered negligence if a physician orders the nurse to
administer a prescription, and the nurse did not do so.

Requirements to establish Negligence

There are four legal requirements that must be met for negligence to be proved:-

 A standard of care exists.

 A breach of duty or failure to meet the standard of care has occurred.
 Damages or injury has resulted from the breach of duty. (This could be commission of
an inappropriate action or omission of a necessary or appropriate act).

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 The injury or damage must result from the nurse’s negligence.
I have never met a nurse whose goal was to be negligent, but it doesn’t happen.
Examples of negligent acts are:-

 Leaving a patient’s bed in high position with the side rails down and the patient gets
confused during the night and falls out of bed.
 Committing medications errors of either omission (not giving the drug) or commission
(giving the wrong drug).
 Breaking sterile technique when changing a dressing, with a resultant wound infection.
 Mistakenly ambulating a patient who is on bed rest.
Nurses are not supposed to make mistakes, yet the best educated and well intentioned
nurse can. To avoid neglect, you need to pay attention to the details of your
assignment and focus on managing your workload efficiently. It is important to
practice such skills now while you are a student and have an instructor to help you
determine the most effective way to get your work done.

g. Malpractice
Malpractice is a term used for negligence. Malpractice specifically refers to
negligence by a professional person with a license. You can be sued for malpractice
once you have your LPN license. If you are a nursing assistant right now, you may be
negligent, but it wouldn’t be malpractice because you are not licensed.

h. Fraud
Few cases of fraud exist in nursing, but it does need to be mentioned. Fraud
is a deliberate deception for the purpose of personal gain and usually is prosecuted as a
crime. Most courts are harder on cases of fraud compared with cases of negligence or
malpractice because fraud is deliberate and results in personal gain.

i. Assault and Battery

It is found that most nurses do not understand the definitions for assault and
battery. It is important to your practice that you do understand them.

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Assault is the threat of unlawful touching of another, the willful attempt to harm
someone. Battery is the unlawful touching of another without consent, justification, or
exercise. In legal medicine battery occurs if a medical or surgical procedure is
performed without patient consent.

In both situations, it is not necessary for harm to occur. The events simply
need to happen. If you understand and practice the caring and empowering concepts
shared in this test, you should never have to be concerned about assault and battery.

Assault can be verbally threatening a patient. Rather than threaten a patient,

you need to use your creative tactics to assist the patient in whatever is his or her
choice in the matter. You do not have to hurt the person. If you practice transpersonal
caring, however you should not have to be concerned with these legal issues.

j. False Imprisonment
Preventing movement or making a person stay in a place without obtaining
consent is false imprisonment. This can be done through physical or non physical
means. Physical means include using restraints or locking a person in a room.Insome
unique situations, restraints and locking patients in a room are acceptable
behaviours.This is the case when a prisoner comes to the hospital for treatment or
when a patient is a danger to self or others. In these situations, be sure you know the
standards of care and the institution’s policies regarding physical restraints. To restrain
a person is a serious decision. It requires a physician’s order and permission of the
patient or the patient’s family members.

It used to be common practice to use restraints on nursing home residents

who wandered or had other behaviours that were difficult to manage. This is no longer
an acceptable standard of care. The best approach to avoiding a charge of false
imprisonment is to work closely with patients who seem at risk for confinement. Talk
to them, do an ongoing assessment, assign extra staff to assist the person, or

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implement some other creative way to manage the problem. To resolve such complex
issues is truly practicing the art of nursing.

k. Invasion of privacy
Clients have claims for invasion of privacy’, e.g. their private affairs, with
which the public has no concern, have been publicized. Clients are entitled to
confidential health care. All aspects of care should be free from unwanted publicity or
exposure to public scrutiny. The precaution should be taken sometimes an individual
right to privacy may conflict with public’s right to information for e.g. in case of
poison case.

l. Nurse Practice Act

Each state has what is called a Nurse Practice Act. The guidelines and laws
outlined in the act pertain to all nurses who are licensed in that particular state. Nurse
limitation is one of those laws. Each nurse has a limitation on what he is allowed and
trained to do. He must follow the chain of command, especially with the care of a
patient. If he does not have the authority or knowledge to give a prescription, analyze a
lab report, or advise the patient on treatment, he may not legally do so. Any wrong
information or practice he commits is punishable by the law and the patient or family
may file a suit against him and the health agency or hospital he works for.

m. Patient's Advocate
A nurse has a legal obligation to act as the patient's advocate in case of
emergency. The nurse is to act as the liaison between the patient and the health care
provider, such as a physician. The nurse will monitor the patient, ensuring that if any
complications or abnormalities arise, a physician notified immediately. The nurse is
legally obligated to keep the personal data and information of the patient private; not
doing so is a violation of the code of ethics for nurses.

n. Administering Medication

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 Nurses are responsible for administering the correct doses and medications
to patients. If the nurse gives a fatal dosage amount, she may face legal malpractice
suits. It is also the responsibility to research the patient's records, or ask the patient and
family members if there are any allergies or complications that may pose a risk if a
certain medication is administered.

o. Report It or Tort It
Allegations of abuse are serious matters. It is the duty of the nurse to report
to the proper authority when any allegations are made in regards to abuse (emotional,
sexual, physical, and mental) towards a vulnerable population (children, elderly, or
domestic). If no report is made, the nurse is liable for negligence or wrongdoing
towards the victimized patient.
Examples of legal torts

 Invasion of Privacy example: a nursing student observing a procedure without the

client's consent or taking photos of the client.
 False imprisonment example is telling the client that he/she may not leave the hospital
or the use of restraints.
 Battery example: performing procedure without consent such as resuscitation.
p. Rights to Privacy
The nurse is responsible for keeping all patient records and personal
information private and only accessible to the immediate care providers, according to
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If records
get out or a patient's privacy is breached, the liability usually lies on the nurse because
the nurse has immediate access to the chart.
q. Document, Document, Document
It is the nurse's responsibility to make sure everything that is done in
regards to a patient's care (vital signs, specimen collections, noting what the patient is
seen doing in the room, medication administration, etc.), is documented in the chart. If
it is not documented with the proper time and what was done, the nurse can be held

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 liable for negative outcomes. A note of caution: if there was an error made on the
chart, cross it out with one line (so it is still legible) and note the correction and the
cause of the error.
ii. Legal Issues in specialty and practice area
a. Maternal and infant Nursing
Many legal issues are involved in the care of mother and her infant.
Generally the causes of lawsuits for malpractice in this area may be divided into two
categories who handling the mother and child. Lawsuits brought against physicians/
doctors and nurses differ, reflecting the well- recognized differences between these
professions and their responsibilities.

A likely against a doctor who is in charge of looking after mother and infant might be
one of the following:-

 Failure to diagnose a high risk pregnancy.

 Delay in performing a caesarean section.
 Improper vaginal delivery or failure to perform a caesarean section.
 Improper use of forceps.
 Incidence surrounding including labour and the use of oxytocin.
 Delay in arriving at the hospital.
 Non attendance at the delivery.
The common causes for lawsuits against nurses will include the following:-

 Problems of medication
Nurses are authorized to administration of medication. So many allegations against
nurses with regard to medication dosage, route or time, and failure to monitor side
effects, for e.g. nurses are often involved in the administration of oxytocin for the
augmentation of labour.

 Failure in adequate client monitoring.

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 Nurses are expected to monitor their clients at appropriate time intervals that depend
upon the client’s condition. Labour and delivery pose a unique monitoring challenge,
in that there are two clients to monitor, the mother and baby. The delivering mother
must be adequately monitored to prevent any maternal complications during prenatal
period. Nurses have legal responsibilities regarding fetal monitoring during labour.
And prompt monitoring will be continued during natal period, postnatal period to
prevent complication related to mother and child in respective periods.

 Failure to adequately assess the client.

Every nurse regardless of the area of practice is expected by virtue of his or her
licensure to be capable of performing assessment. The nurse is an important member
of the health care team who is the client constantly, and responsible for the minute by
minute evaluation of the client progress. Nurses in all specialty areas must maintain
the higher level of assessment skills.

 Failure to report changes in the patient

Whenever the nurses’ assessment indicates that the client’s condition has changed, the
nurse must notify the concerned physician. For example the nurses failure in reporting
changes in the child, denied the physician the opportunity to intervene and possibly
save the child’s life. When a nurse reports a client’s changed condition to the
physician, the nurse feels that the physician has not responded in a manner that is in
the client’s best interest, the nurse must proceed up the chain of command until proper
medical care is given to the client. As a patient advocate, nurses must understand that
failing to notify a doctor of a problem often leads to a delay in appropriate medical
care being implemented. This in turn can lead to an injury to the client and a lawsuit.

 Abortions
Abortion is one of the emotionally charged issues confronting nurses. Nurses cannot
be forced to participate in procedures they find morally offensive. Nurses have right to
refuse to assist with abortions. However, nurses cannot attempt to stop an abortion

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 being performed. She can assist with abortion if it is performed under Medical
Treatment of pregnancy Act.

 Nursing care of new born.

There are certain legal requirements in providing nursing care for newborns, such as
properly identifying the infant- mother pair as soon as possible with finger prints, foot
prints and wrist bands. Standards of practice include providing a clear airway,
clamping the umbilical cord, applying antibiotics or silver nitrate to the edges, and
minimizing stress of dying and keeping infant warm. Resuscitation equipment must be
in the delivery room. When a still born infant is delivered, the nurse must record all
events about the delivery. Although the atmosphere in a delivery room is disquieting,
the nurse must complete legal requirement by careful documentation.

 Informed Consent
 Before treatment, diagnostic procedures, or experimental therapy, a patient must be
informed of the reasons for the treatment as well as possible adverse effects and
alternative treatments.
 The physician must obtain signed consent.
 The nurse must ensure that signed consent is in the patient’s chart before the
procedure is performed.
 Prenatal Screening
 Can detect inherited and congenital abnormalities long before birth.
 Early diagnosis may allow repair of an abnormality in utero.
 May force a patient to choose between having an abortion and assuming the
emotional and financial burden of raising a severly disabled child.
 Some feel that the risk it poses to the fetus creates a conflict between the rights of
the fetus and the parents’ right to know the fetus’s health status.
 Helps the patient fully understand the procedure.

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  Pretest and posttest counseling are essential parts of an ethical prenatal- screening
program.
 In vitro fertilization (IVF)
 With IVF, the ovum is fertilized outside the body and then implanted into the
uterus.
 Between 15 and 20 embryos may result from a single fertilization effort.
 Only 3 to 5 of these embryos are implanted in the women’s uterus.
 Ethical questions arise as to what to do with remaining embryos.
 Although the procedure has allowed infertile couples to have children, some are
concerned that it is unnatural.
 Surrogacy
 A surrogate mother carries a fetus for another couple, with the expectation that the
couple will adopt the neonate after he is born.
 Questions have evolved over the surrogate mother’s legal rights to the infant.
 Fetal tissue research
 Fetal tissue has facilitated scientific research for Parkinson’s disease, Alzheimer’s
disease, diabetes, and other degenerative disorders.
 Transplanted fetal nerve cells help to generate new cells in the patient that somehow
reduce symptoms.
 Immaturity of the fetal immune system reduces the chances of the recipient rejecting
the tissue.
 Some are concerned whether the number of abortions will increase in response to the
need for tissue and whether this is an ethical use of human tissue.
 Preterm and high risk neonate treatment
 Medical advances have improved survival rates for high risk neonates.
 Some are concerned about the physical, psychosocial and economic costs.
 The nurse must present all available options in a compassionate, unbiased manner
using simple terms.

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 The nurse must help family members consider the pros and cons both initiating and
withholding treatment.
b. Pediatric Nursing
As in all areas of nursing practice, negligence involving pediatric clients is
possible. Paediatric nurses are responsible for preventing children, in their care, from
accidentally harming themselves. Cribs which sometimes have a restraining device
over the top are designed to keep infants and toddlers from climbing out of bed and
injuring themselves. All poisonous substances and sharp objects should be kept out of
the reach of children. Children should be kept under constant surveillance to minimize
opportunities for accidental harm. It is advisable that the health care professional
including nurses should report to the concerned authority if they come across the
suspected cases may be liable for civil or criminal legal action.

Every state and province with child abuse legislation requires that
suspected child abuse or neglect be reported. HealthCare professionals such as nurses
are mandated to report suspected cases. Healthcare professionals who don’t report
suspected child abuse or neglect may be liable for civil or criminal legal action.

Paediatric nurses are responsible for protecting children from accidently

harming themselves. All poisonous substances and sharp objects should be kept out of
reach to the children. Children should be kept under constant surveillance to minimize
opportunities for accidental harm.

c. Medical Surgical Nursing

As in the case of paediatric clients, disoriented adults may require form of
restraints to prevent accidental self injury. Standard care, laws and regulations about
the use of restraints and supervision apply to nursing practice with medical surgical
patient. Side rails are available on most hospital beds for adult patients. Some
disoriented older patients may also require belt restraints to prevent them falling of the
bed. If patients fall off bed and injure themselves, they may bring a lawsuit against the

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 nurses and hospital. Nurses are responsible for performing all procedures correctly and
exercising professional judgement. A nurse who does not meet the accepted standards
of practice or who perform duties in a careless fashion runs a risk of being found
negligence. Some common acts of negligence in medical surgical nursing are as
follows:-

 Over looked sponges, instruments needles

In the operation theatre, it is a responsibility of the nurse to count the sponges,
instruments, needles before the closure of the abdomen or any cavity. The nurse may
be liable if she makes an error in their court.

 Burns
The professional nurse is required to know the cause and effect of any heat application
so as to avoid burns. Some of the common heat applications are applications, of hot
water bags, heating pads, double sitz bath etc. The nurse could be held liable if she/he
neglects to take proper safety measure prior to application of such measures.

 Falls
The nurse could be held liable if a patient falls from the bed or due to improper
securing of patient on examination table or improper application of restraint or
provision of a proper bed for an unconscious patient or a child.

 Injury due to the use of defective apparatus or supplies

The defective bed pans infect patients. The nurse could be held liable if she uses
equipment or supplies them which she or he knows to be faulty, e.g. the use of
unsterilized gauze of surgical dressings.

 Injury due to administration of wrong medicine, wrong dosage and wrong

concentration.
Administration of medicine without prescription by the concerned authority, mixing
up of poisonous and non poisonous drug in cupboards leading to errors, and failing to

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 identify right medication for right patient, in right dosage, at right time, considered as
negligent act can be liable to be used.

 Assault and battery

Failure to take the informed consent of the patient prior to any procedure, treatment,
investigation or operation, the nurse be held liable.

 Failure to report accidents

The nurse has a moral and legal responsibility to report to the concerned authority any
accidents, losses or unusual occurrences. Failure to do this is an act of negligence.

 Maintenance of records and reports

Failure to maintain accurate record and reports or removing a position of record may
also make the nurse liable. Nurses working in critical care units are also legally
accountable for performing their duties. Critical care nurses require additional training
and ongoing intensive education to provide them with information about advances in
care methods to handle high- tech- machines and electric and electronic apparatus in
addition to other critical care nursing measures. The possible legal problems for
critical care nurses are associated with use of electronic monitoring devices. No
monitor can be considered totally reliable and nurse must not completely depend on it.
These may be electrical hazards. The equipment should be checked routinely by
engineers to ensure that a patient will not receive any electrical shock.

 Critical care units

Nurses working in critical care settings are legally accountable for performing their
duties. Critical care nurses require additional training and ongoing in service education
to provide them with information about advances in methods of patient care. Possible
legal problems for critical care nurses are associated with the use of electronic
monitoring devices. No monitor can be considered totally reliable, and the nurse must
not completely depend on it. There may also be electrical hazards. The equipments
should be checked routinely.

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 d. Psychiatric Nursing
The practice of psychiatric nursing is influenced by the law, particularly in
concern for the rights of patients and the quality of care they are receiving. A
psychiatric nurse should be sufficiently acquainted with the legal aspects of psychiatry
so that she/he can be aware of the patient’s rights and can avoid giving poor advice or
innocently involving herself/himself in a legal entanglement.

 Informal Admission
This type of admission to the psychiatric hospital occurs in the same way as a person is
admitted to a general medical hospital, i.e. without formal or written application. The
individual is then free to leave at any time, as he would be in a general medical hospital.

 Restraints
 Discharge
e. Community Health Nursing
In olden days nurses were working under the control and supervision of
doctors. But in modern practice nurses are able to assess, diagnose, plan, implement
and evaluate nursing care independently.

As we begin professional practice, it is essential to understand the law that

defines the nurse’s responsibility and duties. Especially the community health nurse
must be very careful while doing services in the community. Because there is team of
people working in the hospital. Whereas in the community the community health
nurses are alone and most of the time she is in a position to implement the services at
home. So, she must be more careful and she should have enough knowledge on legal
issues.

a. Intentional Torts
 Assault: It is a threat or an attempt to make bodily contact with another person
without that person’s consent.

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 Battery: It is an assault that is carried out with willful angry and violent or negligent
touching of another person’s body or clothes.
Examples:-

 Forcibly removing patient’s cloth.

 Injection with force or when refused by patient.
 Pushing a patient in floor or the chair.
 Defamation: It is an intentional tort makes derogatory remarks about another.
Slander: oral defamation of character.

Libel: Written defamation (petition)

E.g. About patient or co workers.

 Invasion of Privacy
 All information should be confidential.
 Interacting with the family members.
 Avoid unnecessary exposure.
 Checking of all graduates or machines.
 Carryout research activities.
 Using tape recorder, video or photos.
 False Imprisonment: A person cannot be legally forced to remain in health centers or
hospital. (Unjustified intension)
 Fraud: Willful and purposeful interpretation or misinterpreting the outcome of
procedure or a treatment. (License may be prosecuted under the NP Act.
b. Unintentional Torts
 Negligence: An act of negligence may be enacting of omission or commission.
 Malpractice or Negligence
 Liability: It involves four elements that must be established to prove that malpractice
or negligence has occurred.

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 Duty: Execution of safety measures.
 Breach of Duty: Failure to note and report to the higher authority about the
seriousness.
 Causation: Failure to use appropriate safety measures.
 Damages: Lengthened hospital stay and need for rehabilitation (Injection abscess)
Nurses Responsibilities

 Practice within the scope of nurse practice act.

 Observe agency policies and procedures.
 Establish standards by using evidence based practice.
 Always prefer patient’s welfare.
 Be aware of relevant law and understand the limits.
 Practice within the area of individual competence.
 Upgrade technical skills by attending continuing nursing education (CNE) and seeking
certification.
 Following the standards of care and referral services.
 Ensure patient safety.
 Proper action for needs and problems and appropriate treatment.
 Monitor the programme and proper reporting.
 Verify the medication errors and reactions.
Legal Safe Guards of Community Health Nurses

 Informed consent: Granted freedom, written or oral form (procedures, expected

outcome, complication, side effects, and alternative treatment.
 Contracts: Exchange of promises between two parties. The agreement may be written
or oral. (E.g. patient and his family and health care team.)
 Collective bargaining: Policies, legal procedures, up to date knowledge.
 Competent practice: It is most important and best legal safeguard.
Respecting Legal Boundaries

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 Institutional policies/ procedures should be adopted.
 Respecting individual rights.
 Developing rapport and working relationship with the community.
Keeping careful documentation for all activities.
c. Legal, Ethical, Professional Issues in Nursing.

Nurses are subject to a plethora of ethical, legal and professional duties

which are too numerous to discuss within this thesis. Therefore the main professional,
ethical and legal duties will be discussed. These three main duties are generally
considered to be to respect a patient's confidentiality and autonomy and to recognise
the duty of care that is owed to all patients. These three main duties are professional
duties, however there are legal implications if they are breached, therefore they are
also legal duties; ethical considerations arise in contemplation of these duties, such as
consideration of when they can be breached and they are therefore ethical duties as
well. Before considering the main duties, consideration will be given to the regulatory
body of nursing, the GMC.

 The Nursing and Midwifery Council

The medical and nursing professions are bound by their own code of ethics
which is enforced by disciplinary procedures. The professional governing body has for
the most part a more immediate influence over the conduct of its members than does
the law, which is invoked relatively rarely in medical matters.

The NMC is a regulator of professional standards. Central to its regulatory

function is the Register of Medical Practitioners. The register operates as a regulatory
tool in two ways; first of all, by operating the register the GMC is the profession's
gatekeeper, allowing entry only to those who have achieved the required standards for
a 'registered medical practitioner' ('RMP'). Secondly, 'fitness to practice' proceedings
against RMPs may result in their being suspended or erased from the register. As a
means of pre-empting the necessity for disciplinary proceedings, the NMC issues

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 guidance on aspects of a practitioner's duties and responsibilities in areas such as
consent, confidentiality and medical research, to prevent poor practice at source. The
translation of NMC guidance into conduct rests primarily, of course, on the individual
conscience of members of the profession whom, it is hoped, adhere to the guidance on
a day to day basis.

 Respecting Confidentiality
The Blue Book sets out the rules on patient confidentiality and it stipulates
that Patients have a right to expect that information about them will be held in
confidence by their doctors. Confidentiality is central to trust between doctors and
patients. Without assurances about confidentiality, patients may be reluctant to give
doctors the information they need in order to provide good care.

Rarely, cases may arise in which disclosure in the public interest may be justified, for
example, a situation in which the failure to disclose appropriate information would
expose the patient, or someone else, to a risk of death or serious harm.

 Respecting Autonomy
The right to determine what happens to ones own body is the right to
autonomy. The words autonomy and autonomous are used in respect of a capacity, a
condition and a right. Successful relationships between doctors and patients depend on
trust. To establish that trust you must respect patients' autonomy - their right to decide
whether or not to undergo any medical intervention even where a refusal may result in
harm to themselves or in their own death. Patients must be given sufficient
information, in a way that they can understand, to enable them to exercise their right to
make informed decisions about their care. Any adult, mentally competent person has
the right in law to consent to any touching of the person. If he is touched without
consent or other lawful justification, then the person has the right of action in the civil
courts of suing for trespass to the person - battery where the person it actually touched,
assault where he fears that he will be touched. The fact that consent has been given

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 will normally prevents a successful claim for trespass. However, it may not prevent an
action for negligence arising on the grounds that there was a breach of duty to care and
inform the patient.

VI. Common causes of Legal Issues

 Professional negligence. E.g. ignoring the seriousness.

 Practicing medical without license in the community.
 Obtaining nursing license by fraud or allowing others to use your license.
 Felony conviction for any offence.
 Participating in criminal abortion. E.g. Quacks.
 Not reporting substandard medicine or nursing care.
 Providing patient care while under the influence of alcohol or drugs.
 Giving narcotics without an order.
 Falsely holding oneself as family practitioner of nurse practitioners.
VII. Processes that can be used in Professional and Legal regulation of nursing
practice

S.N Process
1 Accreditation Education programme is evaluated and recognized by National
. Accreditation Board.
2. Licensure The state determines certain minimum requirement to practice
as nurse. (e.g. Negligence, malpractice, wrong treatment and
alcoholism)
3. Certification Entry level competence. Specific knowledge and experience in
specified areas needed.
4. Standards Guidelines issued by councils, Qualifications, Standards, rules.
5. Nurse Violation of rule care result in disciplinary action
Practice Act

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VIII. Legal Safe Guards and nursing practice

1. Physician’s Order: Physician is responsible for directing medical treatment.

Nurses are obligated to follow physician’s oders unless they believe that the orders
are not accurate or would be detrimental to the clients. A nurse carrying out an
inaccurate order may be legally responsible for any harm suffered by the client.
Verbal orders are not recommended because they have possibilities for error. If a
verbal order is necessary, during an emergency, it should be written and signed by the
physician as soon as possible, usually within 24 hours.
2. Short- staffing: The issue of inadequate staff may arise sometimes. Legal
problems may arise if there is not enough nurse to provide competent care. If assigned
to take care of more clients than is reasonable, nurse should attempt to reject
assignments by informing the nursing supervisor that they are inappropriate. Nurses
should not walk out when staff is inadequate because charges of ababdonment can be
made.ack of experience in taking care of the type of clients in the new nursing unit.
They should also request for an orientation about the unit.
3. Floating: Nurses are sometimes required to ‘float’ from the area in which they
normally practice to other nursing units. Nurses who float should inform the
supervisor about any
4. Informed consent: Granted freedom, written or oral form (procedures, expected
outcome, complication, side effects, and alternative treatment.
5. Contracts: Exchange of promises between two parties. The agreement may be
written or oral. (E.g. patient and his family and health care team.)
6. Collective bargaining: Policies, legal procedures, up to date knowledge.
7. Competent practice: It is most important and best legal safeguard.

IX. List of do’s and don’ts as guidelines for safe practice

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Do’s

 Documention of all unusual incidences.

 Report all unusual incidences.
 Know your job description.
 Follow policies and procedures as established by your employing agency.
 Keep your registration updated.
 Perform procedures that you have been taught and that are within the standard scope
of your practice.
 Protect patients from injuring themselves.
 Remain alert and focused.
 Establish and maintain rapport with patients and family.
 Seek and clarify orders when the patient’s medical condition changes.
 Practise safety with physician’s verbal orders.
Don’ts

 Remove side rails from patient’s bed unless there is an order or hospital policy to do
so.
 Allow patients to leave the hospital or nursing home unless there is an order or a
signed release.
 Accept money or gifts from patients.
 Give advice that is contrary to physician orders or the nursing care plan.
 Give medical advice to friends and neighbours.
 Attempt to practice medicine.
 Witness a patient’s will.
 Take medications that belong to patients.
 Worked as a licensed practical/vocational nurse in a state in which you are not
licensed.
X. ROLES AND FUNCTIONS OF NURSE MANAGER IN LEGAL ISSUES
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The following are the leadership roles and managerial functions of a nurse manager in
legal and legislative issues:-

a. Serve as a role model by providing nursing care that meets or exceeds accepted
standards of care.
b. Is current in the field and seeks professional certification to increase expertise in a
specific field.
c. Reports substandard nursing care appropriate authorities.
d. Fosters nurse/ patients relationships that are respectful, caring and honest, thus
reducing the possibility of future lawsuits.
e. Joins and actively supports professional organizations to strengthen the lobbying
efforts of nursing in health care legislation.
f. Practices nursing within the area of the individual competence.
g. Prioritizes patient’s rights and welfare first in decision- making.
h. Demonstrates vision, risk taking, and energy in determining appropriate legal
boundaries for nursing practices thus defining what nursing is and should be in the
future.
i. Is knowledgeable responding sources of law and legal doctrines that affect nursing
practice?
j. Delegates to subordinates wisely, looking at the managers scope of practice and that
of those they supervise.
k. Understands and adheres to institutional policies and procedures.
l. Practices nursing with scope of state nursing within the scope of the state nurse
practice act.
m. Monitors subordinates to ensure that they have a valid, current and appropriate license
to practice nursing.
n. Uses foresee ability of harm in delegation and staffing decisions.
o. Increases staff awareness of intentional torts and assists them in developing strategies
to reduce their liability in these areas.

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p. Provides educational and training opportunities for staff on legal issues affecting
nursing practice.
XI. CONCLUSION

The above mention administration practice are highly indispensible for

effective operation of the hospital and the maintaining and practicing the above
mention procedures give to the nurses for acquittal from the misuse of legal
responsibility. It assists in maintaining a standard of nursing practice by making
accountable under the law. It should be recognized that there are limits to the
contribution law can make to some topics (Dickinson 2002). The more wider topics
such as consent and confidentiality discussed above also very often require not only
knowledge of the law but full understanding of the ethical and professional duties.
Each patient will present a different legal, ethical or professional question and no two
situations will or should be dealt with in the same way as each patient is an individual.

BIBLIOGRAPHY

1. Ann Kobs “Ethics and patient rights, “Nursing management” Volume. 28, No-7,
July – 1997, p.no: 20.

2. BT Basavanthappa. Nursing Administration. 2nd edition. New Delhi: Jaypee

Brothers Medical Publishers; 2009.

3. Dc Joshi, Mamta Joshi. Hospital Administration. 1 st edition. New Delhi: Jaypee

Brothers Medical Publishers; 2009.

4. Mary Ann Anderson. Nursing Leadership, Management, and Professional Practice

for the LPN/LVN in Nursing School and Beyond.3rd edition. United States of
America. Davis Company publishers; 2001.

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5. Marry Lucita. Nursing Practice and Public Health Administration. 2 nd edition.
Angamaly: Elservier publishers; 2007.

6. Tonia DandryAiken(2004) legal, ethical political issues in nursing(2 nd edition) the

Taber’s publishers, Philadelphia. Page no56-79
7. Harjinder Kaur (2010)The Nursing Journal of India,(volume 1),printed and
published by TNAI, Florence Nightingale Lane, New Delhi,Page No. 116-117
8. www.mnhospitals.org/Portals/0/Documents/.../Count-Principles.doc

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