STUDENT ACTIVITY HES 008 (Health Education)

SHEET
BS NURSING / FIRST YEAR
Session # 2

LESSON TITLE : Ethical, Legal, and Economic

Foundations of the Educational Process

LEARNING OUTCOMES:
At the end of the lesson, the nursing student can:

1. Identify the six major ethical principles.

Materials: Hand-outs, Pen and Paper,
2. Distinguish between ethical and legal
Notebook
dimensions of the healthcare delivery system,
including patient education; and
3. Discuss the importance of nurse practice acts.
4. Describe the legal and financial implications of
documentation.
5. Define the ethical, legal, and economic References: Bastable,S.(2019), Ethical, legal,
importance of federal, state, and accrediting and economic foundations of the educational
body regulations and standards in the delivery process,Chapter2 Overview of Education in
of healthcare services; and Healthcare, p.35,p.53,Nurse as Educator 5th
6. Differentiate among financial terms associated Edition
with the development, implementation.

LESSON PREVIEW / REVIEW (5 minutes)

You should be ready for the activity prepared by your instructor to gauge the knowledge acquisition from past lessons.

MAIN LESSON (50 minutes)

A Differentiated View of Ethics, Morality, and the Law

1. Natural law (basis)
2. Deontological (Golden Rule)
3. Teleological (greatest good for the greatest number)

• Ethics (guiding behavioral principles)

• Inherent in these natural laws are, for example, the principles of respect for parents, respect for others, truth
telling, honesty, respect for life, and purity of heart
• Ethics as a discipline interprets these basic principles of behavior in broader terms and assumes argumentative
discourse in favor of particular postures.
• Immanuel Kant promulgated the deontological notion of the “Golden Rule,”

• John Stuart Mill, who purported a teleological approach.

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 • DEONTOLOGY (from the Greek word deon, which means “duty” and logos which means “science” or “study”)
• It is an ethical belief system that stresses the importance of doing one’s duty and following the rules.
• Respect for an individual's right is the key, and one person should never be treated merely for the benefit or well –
being of another person or group.
• TEOLOGICAL or UTILITARIAN approach allows the sacrifice of one or more individuals so that a group of
people can benefit in some important way.
• This approach believed that given the alternatives, choices should be made that result in the greatest good for
the greatest number of people.
• Likewise, the legal system and its laws are based on ethical and moral principles that, through experience and
over time, society has accepted as behavioral norms.
• This relationship accounts in part for the fact that the terms ethical, moral, and legal are so often used in
synchrony.
• Ethics refers to the guiding principles of behavior, and ethical refers to norms or standards of behavior.
• Although the terms moral or morality are generally used interchangeably with the terms ethics or ethical, one can
differentiate the notion of moral rights and duties from the notion of ethical rights and duties
• Moral refers to an internal value system (the “moral fabric” of one’s being). This value system, defined as
morality, is expressed externally through ethical behavior.
• Ethical principles deal with intangible moral values, so they are not enforceable by law, nor are these principles
laws in and of themselves
• Legal rights and duties, on the other hand, refer to rules governing behavior or conduct that are enforceable
under threat of punishment or penalty, such as a fine or imprisonment or both
• The intricate relationship between ethics and the law explains why ethics terminology, such as informed consent,
confidentiality, non maleficence, and justice, can be found within the language of the legal system.
• Practiced Acts are documents that define a profession, describes the profession’s scope of practice, and provide
guidelines for state professional board of nursing regarding standard for practice, entry to profession via licensure,
and disciplinary actions that can be taken if necessary.
• Practiced Acts were developed to protect the public from unqualified practitioners and to protect the professional’s
title

Ethics (guiding behavioral principles), ethical (societal behavior standards)

Moral values (internal belief system)
Ethical dilemmas (moral conflict)
Legal rights and duties (rules governing behavior, enforceable by law)
Practice acts (documents defining a profession)

Evolution of Ethical and Legal Principles in Health Care

Charitable Immunity
Cardozo Decision of 1914
A. Informed consent
a. Informed Consent: the right to full disclosure; the right to make one’s own decisions
B. Right to self-determination
a. Right to self-determination: the right to protect one’s own body and to determine how it shall
be treated

• Informed consent, which is a basic tenet of ethical thought, was established in the courts as early as 1914 by
Justice Benjamin Cardozo
• Cardozo determined that every adult of sound mind has a right to protect his or her own body and to determine
how it shall be treated.
• Although the Cardozo decision was of considerable magnitude, governmental interest in the bioethical
underpinnings of human rights in the delivery of healthcare services did not really surface until after World War II.
• Over the years, legal authorities such as federal and state governments maintained a hands-off posture when it
came to issues of biomedical research or physician–patient relationships.
• However, human atrocities committed by the Nazis in the name of biomedical research during World War II
shocked the world into critical awareness of gross violations of human rights

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 • 1950, the American Nurses Association (ANA) developed and adopted a Code for Nurses with Interpretative
Statements, which has since been revised and updated several times (ANA, 1976 and 1985). The latest revision
of the ANA’s Code (now entitled the Code of Ethics for Nurses with Interpretive Statements) was released in 2001
for implementation in the new millennium.
• This code represents an articulation of professional values and moral obligations in relation to the nurse–patient
relationship and in support of the profession and its mission.

1. Honor the human dignity of all patients and coworkers.

2. Establish appropriate nurse – patient boundaries, and focus on interdisciplinary collaboration.
3. The nurse – patient relationship is grounded in the privacy and confidentiality
4. The nurse is accountable for the personal actions and the behaviors of those persons to whom the nurse has
delegated responsibilities
5. The nurse is responsible for maintaining competence, preserving integrity and safety, and continuing personal
growth.
6. The nurse has responsibility to deliver high – quality care to patients.
7. The nurse contributes to the advancement of the profession.
8. The nurse participates in global efforts for both health promotion and disease prevention.
9. Involvement in professional nursing organizations supports the development of social policy.

Government Regulations & Professional Standards

1. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research
2. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research
3. American Medical Association’s The Principles of Medical Ethics
4. American Nurses Association’s Code of Ethics for Nurses with Interpretative Statements
5. American Hospital Association’s Patient Care Partnership

Application of Ethical and Legal Principles to Patient Education

6 Ethical Principles
1. Autonomy
2. Veracity
3. Confidentiality
4. Nonmaleficence
1. Negligence
2. Malpractice
3. Duty
5. Beneficence
6. Justice

1. AUTONOMY is derived from the Greek words auto (“self”) and nomos (“law”) and refers to the right of self-
determination. Laws have been enacted to protect the patient’s right to make choices independently

Patient Self-Determination Act (PSDA) requires, either at the time of hospital admission or prior to the initiation of
care or treatment in a community health setting, “that every individual receiving health care be informed in writing of
the right under state law to make decisions about his or her health care, including the right to refuse medical and
surgical care and the right to initiate advance”

• The nurse’s responsibility to ensure informed decision making by patients, which includes but is certainly not
limited to advance directives (e.g., living wills, durable power of attorney).
• Documentation of such instruction must appear in the patient record, which is the legal document validating that
such instruction took place.
• Another example of autonomy is the development and use of patient decision aid interventions that are designed
to assist patients in making informed treatment choices.
• These patient decision aids, which include printed materials, videos, and interactive web-based tutorials, provide
patients with information about specific health issues, diagnoses, treatment risks and benefits, and questionnaires
to determine whether they need more information.

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 2. Veracity or truth telling, is closely linked with informed decision making and informed consent.
• An individual has the fundamental right make decisions about his or her own body.
• This ruling provided a basis in law for patient education or instruction regarding invasive medical procedures,
including the truth regarding risks or benefits involved in these procedures.

Four Elements Making Up the Notion of Informed Consent

Competence, which refers to the capacity of the patient to make a reasonable decision.
Disclosure of information, which requires that sufficient information regarding risks and alternative treatments be
provided to the patient to enable him or her to make a rational decision
Comprehension, which speaks to the individual’s ability to understand or to grasp intellectually the information being
provided.
A child, for example, may not yet be of an age to understand any ramifications of medical treatment and must,
therefore, depend on his or her parents to make a decision that will be in the child’s best interest
Voluntariness, which indicates that the patient has made a decision without coercion or force from others.

While three of the four elements might be satisfied (for example, that the client is of sound mind, that sufficient
information has been provided to enable the client to make an informed decision, and that he or she has the capacity
to fully understand the information being explained) the client might still decide to reject the “treatment of choice.”

• This decision could be due to the exorbitant cost of a treatment or to certain personal or religious beliefs
• Whatever the case, it must be recognized by all concerned that a competent, informed client cannot be forced to
accept treatment as long as he or she is aware of the alternatives as well as the consequences of any decision

A final dimension of the legality of truth telling relates to the role of the nurse as expert witness.
Professional nurses who are recognized for their skill or expertise in a particular area of nursing practice may be
called on to testify in court on behalf of either the plaintiff (the one who initiates the litigation) or the defendant (the
one being sued)
Regardless of the situation, the nurse must always tell the truth and the client (or his or her health proxy) is always
entitled to the truth.

3. Confidentiality refers to personal information that is entrusted and protected as privileged information via a social
contact, healthcare standard or code, or legal covenant.

As a consequence, the nurse may not disclose information acquired in a professional capacity from a patient without
the consent of the patient “unless the patient has been the victim or subject of a crime, the commission of which is the
subject of legal proceeding in which the nurse is a witness”

This discussion of confidentiality gives rise to the need to distinguish between the concepts of what is private, what is
privileged, and what is confidential.

The diagnosis of acquired immune deficiency syndrome (AIDS) readily lends itself to the clarification of these
concepts. Despite its communicability, the person with a diagnosis of AIDS is protected by laws promulgated by
federal and various state governments. Within this context, AIDS is considered to be private information.

It need not be disclosed in the workplace, the home, or other social settings. By federal mandate (and in some states),
this information is considered to be highly personal, the privacy of which is regarded as a fundamental right of the
person.

AIDS is further considered to be privileged information. Such information is “owned” by the patient alone and is
subject to disclosure only at his or her individual discretion. Once this information is shared between the nurse and the
client, it cannot be shared with other health professionals unless authorized by the client.

The diagnosis of AIDS is also protected by law as confidential. Thus anyone not involved in a client’s care has no
right to private or privileged information regarding the health status of the client.

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 These protections are applicable despite the fact that AIDS is a communicable disease.

4. Nonmaleficence is defined as “do not harm” and refers to the ethics of legal determinations involving negligence
and/or malpractice

Negligence is define as “conduct which falls below the standard established by law for the protection of others
against unreasonable risk of harm”
Professional Negligence “involves the conduct of professionals that falls below a professional standard of due care”

Due care is “the kind of care healthcare professionals give patients when they treat then attentively and vigilantly so
as to avoid mistakes”.

For negligence to exist, there must be a duty between the injured party and the person whose actions (or
nonactions) caused the injury.
A breached of that duty must have occurred, it must have been the immediate cause of the injury, and the injured
party must have experienced damages from the injury.

Malpractice “refers to limited class of negligent activities committed within the scope of performance by those
pursuing a particular profession involving highly skilled and technical services”
Malpractice has been specifically defined as “negligence, misconduct, or breach of duty by a professional person that
results in the injury or damage to the patient”

Thus, malpractice is limited in scope to those whose life work requires special education and training as dictated by
specific educational standards.
In contrast, negligence refers to all improper and wrongful conduct by anyone arising out of any activity.

Malpractice usually arises because of the following:

1. Failure to follow standards of care
2. Failure to use equipment in a responsible manner
3. Failure to communicate
4. Failure to document
5. Failure to assess and monitor
6. Failure to act as patient advocate
7. Failure to delegate task properly

5. Beneficence is defined as “doing good” for the benefit of others.

It is a concept that is legalized through adherence to critical tasks and duties contained in job descriptions; in policies,
procedures, and protocols set forth by the healthcare facility; and in standards and codes of ethical behaviors
established and promulgated by professional nursing organizations.

Adherence to these various professional performance criteria and principles, including adequate and current patient
education, speaks to the nurse’s commitment to acting in the best interest of the patient. Such behavior emphasizes
patient welfare and deemphasizes the provision of quality care under threat of litigation.

6. Justice speaks to fairness and equal distribution of goods and services.

The law is the “Justice System.”
• The focus of the law is the protection of society; the focus of health law is the protection of the consumer
Decision making for the fair distribution of resources includes the following criteria as define by Tong (2007):
1. To each, an equal share
2. To each, according to need
3. To each, according to effort
4. To each, according to contribution
5. To each, according to merit
6. To each, according to the ability to pay

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The Ethics of Education in Classroom and Practice Settings
• Student-Teacher Relationship (novice and expert)
• Patient-Provider Relationship (respect, trust, and caring; professional-personal boundaries)

The Student – Teacher Relationship

• Students and teachers have their own perspectives, visions, values, and preferences that are unknown to each
other.
• These two world view come together in the classroom. They must be negotiated and understood by each party for
the process of education to proceed with trust and respect
• A balance of power exists between the teacher (expert) and the student (novice).
• The teacher possesses discipline – specific expertise, which is the key to the student’s academic success, career
achievement, and competent care of patients.
• Students must be able to trust their teachers – even instantaneously – and believe that the instruction provided by
them will be accurate, appropriate, and up to date.
• Students have a right to assume their instructors are competent and will employ that competence in the best
interests of the students and the nursing profession.
• Students may experience personal difficulties that can interfere with their studies or with their goals in pursuing a
degree in the health professions.
• Educators can use the following specific criteria to distinguish between interactions that are appropriate in the
context of the educational process and those that are less appropriate or even frankly inappropriate.
▪ Risk of harm to the student or to the student – teacher relationship
▪ Presence of coercion or exploitation
▪ Potential benefit to the student or to the student – teacher relationship
▪ Balance of student’s interests and the teacher’s interests
▪ Presence of professional ideals.

These five criteria can assist the teacher in being fully honest with himself or herself regarding the appropriateness of
counselling the student and can serve as an extremely useful guide in uncertain situations.

Students are autonomous agents. If they choose to follow the prescribed course of study and are successful, they will
develop professional autonomy, attain their professional goals, achieve professional competence, and be equipped to
develop relationships with colleagues and patients.

Students are responsible for speaking up when they experience problems with or obstacles to their learning. Otherwise,
their teachers may make overly ambitious demands on and have unrealistic expectations for students in the learning
process.

Just as students have the right to expect honesty from their teachers, so they have a reciprocal duty to be truthful – such
as when they have not done an assignment or prepared for a class activity or have made mistake.

Taking responsibility for one’s missteps as a student reveals the students commitment to honesty, the primacy of patient
welfare and trustworthiness.

The Patient – Provider Relationship

It is important to recognize the balance of power that exists between a nurse/nursing student and the patient.
The nurse possesses medical expertise: keys to the patient's health, well-being, and ability to work, play, go to school, or
engage in social relationships.

Caring is not only essential for the physical and psychological well-being of the patients but caring also requires getting
involved in a network of relationships to meet patient’s needs.
Legal and Financial Implications of Documentation
• A Patient’s Bill of Rights
• Joint Commission (JC)
• State Regulations

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 • Federal Regulations

•
Patient’s Bill of Rights

“…probably the most undocumented skilled service….” (Casey, 1995)

Documentation is required by:
• JC
• Third-Party Reimbursement: insurance companies, Medicare and Medicaid programs, or “private pay”
• Respondeat Superior: The employer may be held liable for the negligence or other unlawful acts of the employee
during the performance of his or her job-related responsibilities.
• Documentation
• EMR/EHR has advantages and disadvantages
• Informed Consent (legal, ethical, administrative purposes)
Economic Factors of Patient Education: Justice and Duty Revisited
Challenge for healthcare providers:
• Efficient and cost-effective patient education
• Legal responsibility of all nurses
• Little preparation on prelicensure level

Financial Terminology
• Direct Costs
Fixed Costs
Variable Costs
• Indirect Costs
Hidden Costs
• Cost Savings, Cost Benefit, and Cost Recovery (Revenue Generation)

Direct Costs: those that are tangible and predictable, such as rent, food, heating, etc.
Fixed Costs: those that are stable and ongoing, such as salaries, mortgage, utilities, durable equipment, etc.
Variable Costs: those related to fluctuation in volume, program attendance, occupancy rates, etc.

Indirect Costs: those that may be fixed but not necessarily directly related to a particular activity, such as expenses
of heating, lighting, housekeeping, maintenance, etc.

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 Hidden Costs: those that cannot be anticipated or accounted for until after the fact

Cost Savings: money realized through decreased use of costly services, shortened lengths of stay, or fewer
complications resulting from preventive services or patient education

Cost Benefit: occurs when the institution realizes an economic gain resulting from the educational program, such as
a drop in readmission rates

Cost Recovery: occurs when revenues generated are equal to or greater than expenditures

Revenue Generation: income earned that is above the costs of the programs offered

Program Planning and Implementation

• Accurate assessment of direct costs
• Account for indirect costs
• Cover program preparation and development

Cost-Benefit Analysis and Cost-Effectiveness Analysis

• Measuring effectiveness of patient education programs

Relationship of costs and outcomes
Cost-Benefit Analysis
Impact of educational offering on patient behavior
Cost-Effectiveness Analysis

• Cost-Benefit Analysis: the relationship (ratio) between actual program costs and actual program benefits, as
measured in monetary terms, to determine if revenue generation was realized
• Cost-Effectiveness Analysis: refers to determining the economic value of an educational offering by making a
comparison between two or more programs, based on reliable measures of positive changes in the behaviors of
participants as well as evidence of maintenance of these behaviors, when a real monetary value cannot be
assigned to the achievement of program outcomes

State of the Evidence

1. Legal and ethical issues
2. Documentation of practice
3. New technologies
4. Health-related outcomes
5. Economic implications

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. 1 point will be given to every correct
answer and another 1 point for correct rationalization. You have 30 minutes to do this.

Multiple Choice

1. Which of the following Ethical Principles refer to personal information that is entrusted and protected as privileged
information via a social contact, healthcare standard or code, or legal covenant.
A. Autonomy C. Confidentiality
B. Veracity D. Non-maleficence
RATIO: Private details that is confided and secured as privileged information by a social interaction, healthcare norm or code, or legal
covenant is referred to as confidentiality.

2. It is defined as “doing good” for the benefit of others.

A.Beneficence C. Justice

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A. Confidentiality D. Non-maleficence
RATIO: "Doing good" for the benefit of others is characterized as beneficence. It's a concept that's legitimized by following critical
tasks and responsibilities outlined in job descriptions, as well as policies, procedures, and protocols established by the healthcare facility,
and standards and codes of ethical behavior established and promulgated by professional nursing organizations.

3. It is also known as “ truth telling” and is closely linked with informed decision making and informed consent.
A. Autonomy C. Confidentiality
B. Veracity D. Non-maleficence
RATIO: Veracity or truth telling, is closely linked with informed decision making and informed consent. A person's fundamental right
to make decisions regarding his or her own body is unalienable. This decision established a legal foundation for patient education or
instruction about invasive medical procedures, including the truth about the dangers and advantages of these procedures.

4. Which refers to the right of self – determination:

A. Autonomy C. Confidentiality
B. Veracity D. Non-maleficence
RATIO: Autonomy refers to the right to self-determination and is derived from the Greek terms auto ("self") and nomos ("law"). Laws
have been passed to defend the right of patients to make their own decisions.

5. Which “refers to limited class of negligent activities committed within the scope of performance by those pursuing a
particular profession involving highly skilled and technical services”
A. Negligence C. Non-maleficence
B. Malpractice D. Justice
RATIO: Malpractice is defined as a "limited class of negligent acts committed within the scope of performance by those pursuing a
particular profession involving highly skilled and technical services by those pursuing a particular profession including highly skilled
and technical services."

6. Which refers to the guiding principles of behavior;

A. Ethics C. Legal rights and duties
B. Moral D. Practiced Acts
RATIO: The guiding principles of behavior are referred to as ethics. As a discipline, ethics interprets these fundamental principles of
behavior in larger terms and assumes argumentative discourse in support of specific positions.

7. Which documents define a profession and were developed to protect the public from unqualified practitioners and to
protect the professional’s title.
A. Ethics C. Legal rights and duties
B. Moral D. Practiced Acts
RATIO: Practice Acts define a profession and were intended to protect the public and the professional's title from unqualified
practitioners.

8. Which is an ethical belief system that stresses the importance of doing one’s duty and following the rules.
A. Morality C. Beneficence
B. Deontology D. Non maleficence
RATIO: Deontology is a combination of the Greek words deon, which means "duty," and logos, which means "science" or "study." It is
an ethical belief system that stresses the importance of doing one’s duty and following the rules.

9. Informed consent, which is a basic tenet of ethical thought, was established in the courts as early as 1914 by:
A. Immanuel Kant C. Justice Benjamin Cardozo
B. John Stuart Mill D. American Nurses Association
RATIO: Justice Benjamin Cardozo established informed consent as a basic tenet of ethical thought in the courts as early as 1914.

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10. Who purported a teleological approach.
A. Immanuel Kant C. Justice Benjamin Cardozo
B. John Stuart Mill D. American Nurses Association
RATIO: A teleological approach was impersonated by John Stuart Mill.

11. Money realized through decreased use of costly services, shortened lengths of stay, or fewer complications resulting
from preventive services or patient education
A. Cost Savings
B. Cost Benefit
C. Cost Recovery
D .Indirect Costs
RATIO: Cost Savings are the money realized through decreased use of costly services, shortened lengths of stay, or fewer
complications resulting from preventive services or patient education.

12. Those that may be fixed but not necessarily directly related to a particular activity, such as expenses of heating,
lighting, housekeeping, maintenance, etc.
A. Cost Savings
B. Cost Benefit
C. Cost Recovery
D. Indirect Costs
RATIO: Heating, lighting, housekeeping, maintenance, and etc., are examples of indirect costs that are fixed but not always directly tied
to a specific activity.

13. Occurs when revenues generated are equal to or greater than expenditures
A. Cost Savings
B. Cost Benefit
C. Cost Recovery
D. Indirect Costs
RATIO: When revenues generated equal or exceed expenditures, cost recovery occurs.

14. Those are stable and ongoing, such as salaries, mortgage, utilities, durable equipment, etc.
A. Fixed Costs
B. Cost-Benefit Analysis
C. Cost-Effectiveness Analysis
D. Variable Costs
RATIO: Fixed costs are those that are consistent and continuing, such as salaries, mortgages, utilities, durable equipment, and etc.

15. Those related to fluctuation in volume, program attendance, occupancy rates, etc.
A. Fixed Costs
B. Cost-Benefit Analysis
C. Cost-Effectiveness Analysis
D. Variable Costs
RATIO: Variable costs are those that are affected by changes in volume, program participation, occupancy rates, and so on.

LESSON WRAP-UP (5 minutes)

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 Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.

Wrapping Up- Student Reflection:

1. Get 1 whole sheet of paper and write some key things they were able to get from this Session and will explain why.

Ethics – guiding behavioral principles In this Session this topics was enumerated
Ethical – societal behavior standards and differentiated. Terms was defined and
Moral Values – internal belief system explained well. The modules also described
Legal Rights and Duties – rules governing behavior, enforceable by law and discussed how these terms important in
Practice acts – documents defining a profession nursing practice.
Evolution in Ethical and Legal Principles in Health Care
A. Informed Consent
B. Right to self-determination

Application of Ethical and Legal Principles to Patient Education

6 Ethical Principles
1. Autonomy
2. Veracity
3. Confidentiality
4. Nonmaleficence
a. Negligence
b. Malpractice
c. Duty
5. Beneficence
6. Justice
The Ethics of Education in Classroom and Practice Settings
• Student-Teacher Relationship (novice and expert)
• Patient-Provider Relationship (respect, trust, and caring; professional-personal boundaries)
Legal and Financial Implications of Documentation
• A Patient’s Bill of Rights
• Joint Commission (JC)
• State Regulations
- Federal Regulations
Economic Factors of Patient Education: Justice and Duty Revisited
Challenge for healthcare providers:
- Efficient and cost-effective patient education
- Legal responsibility of all nurses
- Little preparation on prelicensure level

Financial Terminology
Direct Costs
Fixed Costs
Variable Costs
Indirect Costs
Hidden Costs
Cost Savings, Cost Benefit, and Cost Recovery (Revenue Generation)

This document and the information thereon is the property of PHINMA

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