LEGAL ASPECTS OF NURSING

The Philippine Nursing Law

Definition and Meaning of Law

The word "law" may be defined as a rule of conduct pronounced by
controlling authority, which may be enforced. There are three essential
characteristics of every law. The first one is the authority or the right to
declare the rule exists. The second is that such rule is pronounced or
expressed and that its source can be identified. Lastly, a right to enforce the
same must be provided.

Nursing Jurisprudence
• department of law which comprises all legal rules and principles
effecting the practice of nursing
• includes the study and interpretation of rules and principles and their
application in the regulation of the practice of nursing

Functions of Law in Nursing

1. provides a framework for establishing what nursing actions in the care of
patients are legal
2. delineates the nurse’s responsibilities from those of other professionals
3. helps to establish the boundaries of independent nursing actions
4. assists in maintaining a standard of nursing practice by making
nurses accountable to the law

Brief History of the Philippine Nursing Law

The first law that had to do with the practice of nursing was
contained in Act No. 2493 in 1915, which regulated the practice of medicine.
This act provided for the examination and registration of nurses in the Philippine
Islands.

During that time, the applicants need to be only twenty years old, of
good physical health and good moral character. Graduates of intermediate
courses of the public school could enter the school of nursing, which was
then giving only two years, and a half of instruction. These graduates were
called first class nurses. Those who desired to be second-class nurses filed an
application with the district health officer in the district where they resided.

In 1919 Act 2808 was passed-this is known as the First True Nursing Law. It
created among others a board of examiners for nurses. However, it was in 1920
that the first board examination in the Philippines was given.

On June 19, 1953, the Philippine Nursing Law or R.A. 877 was passed. This
act regulated the practice of nursing in the Philippines. One of the landmarks in
the history of the nursing profession in the Philippines is the Presidential
Proclamation of a Nurses' Week.

Under Proclamation No. 539 dated October 17, 1958 the President of
the Philippines designated the last week of October every year beginning in
1958 as Nurses' Week.

On June 18, 1966, Republic Act 4704 amended certain portions of R.A.
877. The following were included among the salient changes:
a. The scope of nursing practice was broadened to circumscribe
the whole management of the care of patients and the acts
constituting professional practice of nursing were spelled out to
include such services as reporting, recording and evaluation of a
patient’s case, execution of nursing procedures and techniques,
direction and education to secure physical and mental care and the
application and execution of physician’s orders concerning
treatment and medication.
b. The minimum age required of applicants for admission to the
nurse’s examination was lowered from 21 to 18 years of age, but
no candidate who passed the examination was permitted to practice
the profession until he or she reached the age of 21.

Republic Act 7164, introduced by Senator Heherson Alvarez, codified

and revised all the laws regulating the practice of nursing in the Philippines.
It was known as the Philippine Nursing Act of 1991.

On October 21, 2002, Republic Act No. 9173 otherwise known as

“The Philippine Nursing Act of 2002” replaced R.A. 7164.
 There are laws governing the practice of Nursing, one of which is
House Bill No. 4955, AN ACT PUNISHING THE MALPRACTICE OF ANY
MEDICALPRACTITIONER IN THE PHILIPPINES AND FOR OTHER PURPOSES.

Legal Liabilities in Nursing

As nurses begin their professional obligations, their legal responsibilities
begin as well. Their license to practice attests that they are qualified under
the law to practice their profession. The Philippine Nursing Act of 1992 is
the best guide the nurse can utilize as it defines the scope of nursing practice.
There are also standards of care that may be used as criteria in evaluating their
work. The nurses are enjoined to be familiar with the Philippine Nursing Law,
and the standards of nursing care, other laws which affect nursing practice
and their code of ethics.

Responsibility and Accountability for the Practice of Professional Nursing

When nurses undertake to practice their profession, they are held
responsible and accountable for the quality-of performance of their duties.
Nurses employed in an agency, institution, or hospitals are responsible directly to
their immediate supervisors. Private duty nurses, being independent
practitioners, are held to a standard of conduct that is expected of reasonably
prudent nurses. The standard is clearly defined, legal expectation to which nurses
are held accountable.

A nurse assumes responsibility and accountability for all nursing care

delivered.

Responsibility
• refers to the execution of duties associated with a nurse’s particular role.
That is, the nurse is responsible for providing care within
established standards of the profession. The responsible nurse
demonstrates characteristics of reliability and dependability.

Accountability
• refers to the ability to answer for one’s own actions. The nurse is
accountable to herself most of all. He/she also balances accountability to
the patient, the profession, the employing institution, and society.
 Liability
• an obligation one has incurred or might incur through any act or failure to
act.-When the nurse fails to meet the legal expectations of care, the
client can initiate action if harm or injury is incurred by the client.

Professional Negligence
The term negligence refers to the commission or omission of an act,
pursuant to a duty, that a reasonably prudent person in the same or similar
circumstances would or would not do, and acting or the non-acting is the
proximate cause of injury to another person or his property.

The elements of professional negligence are (1) existence of a duty on the

part of the person charged to use due care under circumstances, (2) failure
to meet the standard of due care, (3) the foreseeability of harm resulting
from failure to meet the standard, and (4) the fact that the breach of this
standard resulted in an injury to the plaintiff.

Malpractice
Malpractice in the usual sense implies the idea of improper or unskillful
care of a patient by a nurse. It would also see that malpractice also denotes
stepping beyond one's authority with serious consequences.

Medical Orders, Drugs, and Medications

R.A. 6675 states that only validly registered medical, dental and
veterinary practitioners, whether in private institution/ corporation or in the
government, are authorized to prescribe drugs. Prescriptions made by
unauthorized persons constitute illegal practice of medicine, dentistry or
veterinary medicine and is punishable under R.A. 2832 of the Medical Act of
1959, R.A. 4419 of the Dental Act, and R.A. 382 or the Veterinary Act.

In accordance with R.A. 5921, or the Pharmacy Act as amended, all

prescriptions must contain the following information: name of the
prescriber, office address, professional registration number, professional tax
receipt number, patient’s/client’s name, age and sex, and date of
prescription. R.A. 6675 requires that the drugs be written in their generic names.
 The dependent and coordinated function of the nurse pertains to the
application and execution of written legal orders of physicians
concerning treatment and medications. Only when these orders are legal in
writing and bear the doctor’s signature does the nurse have the legal right to
follow them. Written orders are better understood and chances of error are
minimized if they are clear, specific, complete and legible.

Verbal orders can be minimized if the nurse seeks a clear

understanding from the physicians in establishing a policy concerning the
importance of written orders.

The general rule requiring a nurse to execute all lawful orders of a

physician is tempered by common sense. The nurse must not execute an order if
she is reasonably certain it will result in harm to the patient. In such case she
must speak out and risk incurring the physician’s resentment or ire rather than a
lawsuit.

It is preferable to raise the matter of carrying out the procedure as a

point of clarification in a tactful, acceptable manner.

A nurse must see to it that she understands the action of a drug, its
minimum and maximum dosages, route of administration, and untoward effects
so that she may skillfully, safely, and effectively carry them out. She should be
able to report and record the effects on the patient so that the doctor can
judge its therapeutic value and know when to discontinue its use.

Tests and treatments should be explained to the patient in

accordance with the general plan of his care so that the patient can give
full consent and cooperate in its implementation. Any unfavorable psychologic
or physical reaction should be likewise reported so that the proper action may be
taken. Sometimes, however, refusal may be due to inaccurate presentation of
facts. Patients must receive special sympathetic attention from the nurses. Every
effort should be made to correct inaccurate views and modify superficially-held
beliefs.

Intravenous Therapy and Legal Implications

Nurses now participate in complex intravenous therapy procedures
that were once performed only by doctors. Because of this change, nurses
must remember that their legal right to give intravenous injections is based on
the Philippine Nursing Act of 1991 Section 28 which states that "in the
administration of intravenous injections, special training shall be required
according to protocol established. "Therefore, nurses have to undertake a
certified training course on intravenous therapy.

In giving intravenous injections, nurses should also follow the policies

of their agencies. Even if nurses have formal training on IV therapy, if the
hospital does not allow them to do so, then they may not do the procedure.

Board of Nursing Resolution no. 8 states that any registered nurse without
such training and who administers IV injections to patients, shall be held
liable, either criminally under Sec. 30 ( c) Art. VII of said law or administratively
under Sec. 21 Art. III or both (whether causing or not injury or death to the
patient).

Telephone Orders
There are legal risks by telephone orders. These may be misunderstood or
misinterpreted by the receiving nurse. Sometimes too, messages from telephones
may sound unclear or garbled because of some trouble in the telephone
lines. Most importantly, the signature of the ordering physician is not
present and this order may later be denied incase errors exist or court
litigations arise.

Consent to Medical and Surgical Procedures

Consent is defined as a “free and rational act that presupposes knowledge
of the thing to which consent is being given by a person who is legally
capable to give consent.” The consent signed by the patient or his authorized
representative/legal guardian upon admission is for the initial diagnosis
and treatment. Subsequent treatments/operations require individual, informed
consent. Before any medical or surgical procedure can be performed on a
patient, consent must be obtained from the patient or his authorized
representative who may be his parent or guardian. It is only in case of emergency
where the consent requirement does not apply.

The physician should give as much information about a contemplated

procedure and the patient should receive enough information to allow him
to give an informed consent for such procedure or treatment. The intentional
touching or unlawful beating of another person without authorization to do so is
a legal wrong called battery.

Nature of Consent. Consent is an authorization, by a patient or a

person authorized by law to give the consent on the patient's behalf
that changes a touching from non-consensual to consensual. It is the
nurse who actually secures the consent of the patient upon
admission. This consent is usually for diagnostic procedures and
initial treatment deemed necessary by the medical staff. To substantiate
the patient’s consent, a written authorization is needed as proof
against any liability that may arise due to an alleged unlawful touching
of a patient.

Informed consent. “It is established principle of law that every

human being of adult years and sound mind has the right to determine
what shall be done with his own body. He may choose whether to be
treated or not and to what extent, no matter how necessary the medical
care, or how imminent the danger to his life or health if he fails to submit
to treatment.”

The essential elements of informed consent include (1) the

diagnosis and explanation of the condition; (2) a fair explanation of
the procedures to be done and used and the consequences; (3) a
description of alternative treatments or procedures; (4) a description
of the benefits to be expected; (5) material rights if any; and (6)the
prognosis, if the recommended care, procedure, is refused.

Proof of Consent. A written consent should be signed to show that

the procedure was the one consented to and that the person understood
the nature of the procedure, the risks involved and the possible
consequences. A signed special consent is necessary before any medical
or surgical treatment is done such as x-rays, special laboratory tests,
blood transfusions, operations, cobalt therapy, or chemotherapy and
the like.

Who Must Consent. Ordinarily, the patient is the one who gives the
consent in his own behalf. However, if he is incompetent (such as in
the case of minors or the mentally ill) or physically unable and is not an
emergency case, consent must be taken from another who is authorized to
give it in his behalf.

Consent of Minors. Parents, or someone standing in their behalf,

give the consent to medical or surgical treatment of a minor. Parental
consent is not needed however, if the minor is married or otherwise
emancipated.

Consent of Mentally ill. A mentally incompetent person cannot

legally consent to medical or surgical treatment. The consent must be
taken from the parents or legal guardian.

Emergency Situation. When an emergency exists, no consent is

necessary because inaction at such time may cause greater injury. A
mother who is on the advanced stage of labor or a patient who goes to the
emergency room gives an implied consent to an immediate treatment or
attendance. However, if time is available and an informed consent is
possible, it is best that this be taken for the protection of all parties
concerned.

Refusal to Consent. A patient who is mentally and legally competent

(sane mind and of legal age) has the right to refuse to permit touching of
his body or to submit to a medical or surgical procedure no matter how
necessary, nor how imminent the danger to his life or health if he fails
to submit to treatment. Examples are patients who, because of their
religious beliefs, may refuse blood transfusion.

A patient may refuse to consent due to inadequate information

regarding the procedure to be done. If after the explanation, he still
refuses to sign the consent form, he should be made to fill out the release
form to protect the hospital and/or agency and its personnel from any
liability that may result from his refusal. If he refuses to sign the release
form, this should be noted in his chart. The competent person has a legal
and ethical right to refuse treatment, and this right is formally established.
 Consent for Sterilization. Sterilization is the termination of the ability
to produce offspring. The husband and the wife must consent to the
procedure if the operation is primarily to accomplish sterilization. When
the sterilization is medically necessary, the sterilization is an incidental
result such as in cases of abruptio placenta, ectopic pregnancies or
ruptured uterus, the patient's consent alone is sufficient.
Medical Records
The value of medical records is both scientific and legal. As a record of
illness and treatment, it saves duplication in future cases and aids in prompt
treatment. The record supplies rich material for medical and nursing research. It
serves as a legal protection for the hospital, doctor and nurse by reflecting the
disease or condition of the patient and his management. Nurses must remember
the rule. "If it was not charted, it was not observed or done.”

In the performance of their duties, nurses are expected to record fully,

accurately, legibly, and promptly their observations from admission to the
time of the patient’s discharge. Daily notes should include not only
medications and treatments given or rendered but also the physical and
emotional symptoms exhibited by the patient. The nurses’ notes are aids to
medical diagnosis and in understanding the patient’s behavior.

Since patients have the right to confidentiality of these records, nurses are
legally and ethically bound to protect the patient’s chart from unauthorized
persons. Permission has to be taken from the hospital authorities for
authorization to secure any information from the patient’s chart.

Nurses are responsible for safeguarding the patient’s record from loss
or destruction or from access by persons who are not legally authorized to read
such.

Legal Responsibilities of Students

Nursing students are responsible for acquiring the knowledge and
skills necessary to become a safe practitioner. Included in this
knowledge and skill development is the awareness of ethical principles and the
process of ethical decision making. Nursing students must act as reasonably
prudent persons, equivalently with education and experience, when
performing nursing duties. They must perform only those tasks that they are
competent to perform.
Liability for the Work of Nursing Students
Under the Philippine Nursing Act of 2002 R.A. 9173, nursing students do
not perform professional nursing. They are to be supervised by their Clinical
Instructors. In order that the errors committed by nursing students will be
avoided/minimized, the following measures should be taken:
1. Nursing students should always be under the supervision of their
Clinical Instructors.
2. They should be given assignments that are in level of their training,
experience and competency.
3. They should be advised to seek guidance specially if they are
performing a procedure for the first time.
4. They should be oriented to the policies of the nursing unit where
they are assigned.
5. Their performance should be assessed frequently to determine their
strengths and their weaknesses.
6. Frequent conferences with the students will reveal their problems,
which they may want to bring to the attention of their instructors or
vice-versa. Discussions of these problems will iron out doubts and
possible solutions may be provided.

Charting Done by Nursing Students

When a nurse or a clinical instructor countersigns the charting of a
nursing student, she attests that she has personal knowledge of information
and that such is accurate and authentic. Anyone who countersigns without
verification commits herself to possible legal risk.

Source: Venzon, L. & Venzon, R. (2010). Professional Nursing in the Philippines 11th edition

***Incident Reports
The primary purpose of an incident report is to document and
prevent possible consequent injuries. Classifying an event, as an incident does
not imply that someone made a mistake, it only means that something unusual
happened.