NCLEX: Legal Aspects of Nursing

Legal Aspects of Nursing: Ethical and Legal Considerations in Intensive Care of the Acutely Ill Neonate

Focus topic: Legal Aspects of Nursing

I. RESPONSIBILITIES OF THE HEALTH AGENCY

Focus topic: Legal Aspects of Nursing

A. Provide a neonatal intensive care unit (NICU) or transfer to another hospital.

B. Personnel—adequate number trained in neonate diseases, special treatment, and equipment.

C. Equipment—adequate supply on hand, functioning properly (especially temperature regulator in incubator, oxygen analyzer, blood-gas machine).

II. INFANTS WHO ARE DYING

Focus topic: Legal Aspects of Nursing

A. Decision regarding resuscitation in cardiac arrest, with brain damage from cerebral anoxia. It is difficult to predict the effect of anoxia in infancy on the child’s later life.

B. Decision to continue supportive measures.

C. Issue of euthanasia, such as in severe myelomeningocele at birth.

  • Active euthanasia (giving overdose).
  • Passive euthanasia (not placing on respirator).

III. EXTENDED ROLE OF NURSE IN NICU—may raise issues of nursing practice versus medical practice, as when a nurse draws blood samples for blood gas determinations without prior order. To be legally covered:

A. The nurse must be trained to perform specialized functions.

B. The functions must be written into the nurse’s job description.

IV. ISSUE OF NEGLIGENCE—such as crosscontamination in nursery.

V. ISSUE OF MALPRACTICE—such as assigning care of an infant who is critically ill on respirator to a student or aide who is untrained.

A. May be liable for inaccurate bilirubin studies for neonatal jaundice; may be legally responsible if brain damage occurs in absence of accurate laboratory tests.

B. May be liable for brain damage in an infant due to respiratory or cardiac distress. Nurse must make sure that there are frequent blood gas determinations
to ensure adequate oxygen to prevent brain damage. Nurse also must make sure that the infant is not receiving too high a concentration of oxygen, which may lead to retrolental fibroplasia.

Legal Aspects of Nursing: Legal Aspects of Psychiatric Care

Focus topic: Legal Aspects of Nursing

I. FOUR SETS OF CRITERIA TO DETERMINE CRIMINAL RESPONSIBILITY AT TIME OF ALLEGED OFFENSE

Focus topic: Legal Aspects of Nursing

A. M’Naghten Rule (1832)—a person is not guilty if:

  • Person did not know the nature and quality of the act.
  • Person could not distinguish right from wrong— if person did not know what he or she was doing, person did not know it was wrong.

B. The Irresistible Impulse Test (used together with M’Naghten Rule)—person knows right from wrong, but:

  • Driven by impulse to commit criminal acts regardless of consequences.
  • Lacked premeditation in sudden violent behavior.

C. American Law Institute’s Model Penal Code (1955) Test

  • Not responsible for criminal act if person lacks capacity to “appreciate” the wrongfulness of it or to “conform” conduct to requirements of law.
  • Excludes “an abnormality manifested only by repeated criminal or antisocial conduct”— namely, psychopathology.
  • Includes “knowledge” and “control” criteria.

D. Durham Test (Product Rule—1954): accused is not criminally responsible if act was a “product of mental disease.” Discarded in 1972.

II. TYPES OF ADMISSIONS

Focus topic: Legal Aspects of Nursing

A. Voluntary: person, parent, or legal guardian applies for admission; person agrees to receive treatment and to follow hospital rules; civil rights are retained.

B. Involuntary: process and criteria vary among states.

Legal Aspects of Nursing

III. LEGAL AND CIVIL RIGHTS OF CLIENTS WHO ARE HOSPITALIZED—the right to:

A. Wear own clothes, keep and use personal possessions and reasonable sum of money for small purchases.

B. Have individual storage space for private use.

C. See visitors daily.

D. Have reasonable access to confidential phone conversations.

E. Receive unopened correspondence and have access to stationery, stamps, and a mailbox.

F. Refuse shock treatments, lobotomy.

IV. CONCEPTS CENTRAL TO COMMUNITY MENTAL HEALTH (COMMUNITY MENTAL HEALTH ACT, 1980)

Focus topic: Legal Aspects of Nursing

A. Systems perspective: scope of care moves beyond the individual to the community, with influences from biological, psychological, and sociocultural forces.

B. Emphasis on prevention: primary (reduce incidents by preventing harmful social conditions); secondary (early identification and treatment of disorders to reduce duration); tertiary (early rehabilitation to reduce impairment from disorders).

C. Interdisciplinary collaboration: flexible roles based on unique areas of expertise.

D. Consumer participation and control.

E. Comprehensive services: ambulatory care, partial hospitalization, 24-hour hospitalization and emergency care; consultation and education; screening services.

F. Continuity of care.

Legal Aspects of Nursing: Legal Aspects of Preparing a Client for Surgery

Focus topic: Legal Aspects of Nursing

I. NO SURGICAL PROCEDURE, HOWEVER MINOR, CAN PROCEED WITHOUT THE VOLUNTARY, INFORMED, AND WRITTEN CONSENT OF THE CLIENT.

A. Surgical permits are witnessed by the physician, nurse, or other authorized person.

B. Surgical permits protect the client against unsanctioned surgery and also protect the surgeon and hospital staff against claims of unauthorized operations.

C. Informed consent means that the operation has been fully explained to the client, including possible complications and disfigurements, as well as whether any organ or parts of the body are to be removed.

D. Adults and emancipated minors may sign their own operative permits if they are mentally competent; permission for surgery of minor children and adults who are incompetent or unconscious must be obtained from a responsible family member or guardian.

E. The signed operative permit is placed in a prominent place on the client’s chart and accompanies the client to the operating room.

F. Legal issues in the emergency department: record keeping plays an essential role in both the prevention and defense of malpractice suits. Detailed documentation not only provides for continuity of care but also perpetuates evidence that care was appropriately given. Records should:

  • Be written legibly.
  • Clearly note events and time of occurrence.
  • Contain all laboratory slips and results of other tests.
  • Describe events and clients objectively
  • Clearly note physician’s parting instructions to the client.
  • Be signed where appropriate, such as with doctor’s orders.
  • Contain descriptions of every event that might lead to a lawsuit, such as fights, injuries, equipment failures.

G. Consent—although there is no law requiring written consent before performing medical treatment, all elective procedures can only be performed if the client has been fully informed and voluntarily consents to the procedure.

  • If informed consent cannot be obtained because of the client’s condition and immediate treatment is necessary to save life or safeguard health, the emergency rule can be applied. This rule implies consent. However, if time allows, it is advisable to obtain either oral or written informed consent from someone who has authority to act for the client.
  • Verbal consents should be recorded in detail, witnessed and signed by two individuals.
  • Written or verbal consent can be given by alert, coherent, or otherwise competent adults, by parents, legal guardian, or person in loco parentis (one standing in for the parent with the parent’s rights, duties, and responsibilities) of minors or adults who are incompetent.
  • If the minor is 14 years old or older, consent must be acquired from the minor as well as from the parent or legal guardian. Emancipated minors can consent for themselves.

Legal Aspects of Nursing: TRENDS IN NURSING PRACTICE

Focus topic: Legal Aspects of Nursing

I. OVERALL CHARACTERISTICS

A. Some trends are subtle and slow to emerge; others are obvious and quickly emerge.

B. Trends may conflict; some will prevail, others get modified by social forces.

II. GENERAL TRENDS

Focus topic: Legal Aspects of Nursing

A. Broadened focus of care—from care of ill to care of sick and healthy, from care of individual to care of family. Focus on prevention of illness, promotion of optimum level of health, holism.

B. Increasing scientific base—in biological-socialphysical sciences, not mere reliance on intuition, experience, and observation.

C. Increasingly complex technical skills and use of technologically advanced equipment, such as monitors and computers.

D. Increased independence in use of judgment, such as teaching nutrition in pregnancy and providing primary prenatal care.

E. New roles, such as nurse clinician, require advanced skills in a particular area of practice.
Examples: psychiatric nurse consults with staff about problems; primary care nurse takes medical histories and does physical assessment; one nurse coordinates 24-hour care during hospital stay; independent nurse practitioner has her or his own office in community where clients come for care; case management.

F. Community nursing services rather than hospitalbased; needs of the healthy are served as well as those of the ill.

G. Development of nursing standards to reflect specific nursing functions and activities.

  • Ensure safe standard of care to clients and families.
  • Provide criteria to measure excellence and effectiveness of care.

III. TRENDS IN CARE OF CHILDBEARING FAMILY

Focus topic: Legal Aspects of Nursing

A. Consumerism:

  • Consumer push for humanization and individualization of health care during the childbearing cycle to reflect client’s role in decision making, preferences, and cultural diversity.
  • Emphasis on family-centered care (including father, siblings, grandparents).
  • Increase in options available for conduct of birth experience and setting for birth: birthing homes, alternative birth center (ABC) in hospitals; birthing chairs; side-lying position for birth; family-centered cesarean birth; healthcare provider (MD, RN, lay midwife); length of postpartum stay.
  • Increased consumer awareness of legal issues, client’s rights.
  • Major nursing role: client advocate.

B. Social trends:

  • Alternative lifestyles of families—single parenthood, communal living, surrogate motherhood, marriages without children.
  • Earlier sexual experimentation—availability of assistance to emancipated minors.
  • Increase in number of older (>38 years) primiparas.
  • Legalization of abortion; availability to emancipated minors.
  • Smaller families.
  • Rising divorce rates.

C. Technologies:

  • Development of genetic and bioengineering techniques.
  • Development of prenatal diagnostic techniques, with options for management of each pregnancy.
  • In vitro fertilization and embryo transplantation.

IV. TRENDS IN COMMUNITY MENTAL HEALTH

Focus topic: Legal Aspects of Nursing

(1960s–1990s)

A. Shift from institutional to community-based care.

B. Preventive services.

C. Consumer participation in planning and delivery of services.

D. Original 12 essential services (1975) reduced to 5 (indicated by asterisk [*]) (1981).

  • 24-hour inpatient care.
  • Ambulatory care.
  • Partial hospitalization (day or night).
  • Emergency care.
  • Consultation and education.
  • Follow-up care.
  • Transitional services.
  • Services for children and adolescents.
  • Services for elderly.
  • Screening services (courts).
  • Alcohol abuse services.
  • Drug abuse services.

E. Protecting human rights of persons in need of mental health care.

F. Developing an advocacy program for those who are chronically mentally ill.

G. Improving delivery of services to underserved and high-risk populations (e.g., minorities).

V. ANA STANDARDS OF CLINICAL NURSING PRACTICE*

Focus topic: Legal Aspects of Nursing

A. Use of nursing process: assessment, nursing diagnosis, planning, implementation, evaluation, outcome identification.                                                                              B. Performance appraisal review.
C. Continuing education.
D. Collegiality; peer review.
E. Ethics.
F. Interdisciplinary collaboration.
G. Research.
H. Resource utilization—utilization of community health systems.

VI. FOUR LEVELS OF NURSING PRACTICE

Focus topic: Legal Aspects of Nursing

A. Promotion of health to increase level of wellness.
Example: provide dietary information to reduce risks of coronary artery diseases.

B. Prevention of illness or injury.                                                                                                                                                                                                      Example: immunizations.

C. Restoration of health.                                                                                                                                                                                                               Example: teach how to change dressing, care for wound.

D. Consolation of dying—assist person to attain peaceful death.

VII. FOUR COMPONENTS OF NURSING CARE

Focus topic: Legal Aspects of Nursing

A. Nursing care activities—assist with basic needs, give medications and treatments; observe response and adaptation to illness and treatments; teach self-care;
guide rehabilitation activities for daily living.

B. Case management—a process that includes coordination of total client care—all health team members should work together toward common goals.

C. Continuity of care—process of ensuring that ongoing physical, medical, and emotional health-care needs are assessed, planned for, and coordinated with all providers,for desired outcomes, without interruption of service when the location of care is transferred.

D. Evaluation of care—flexibility and responsiveness to changing needs: clients’ reactions and perceptions of their needs.

VIII. THREE MAIN NURSING ROLES in relation to care of clients and their families (emphasis of each role varies with the situation, with adaptation of skills and modes of care as necessary)

A. Therapeutic role (instrumental). Function: work toward “cure” in acute setting.

B. Caring role (expressive). Function: provide support through human relations, show concern, demonstrate acceptance of differences.

C. Socializing role. Function: offer distractions and respite from focus on illness.

Legal Aspects of Nursing: NURSING ORGANIZATIONS

Focus topic: Legal Aspects of Nursing

I. INTERNATIONAL COUNCIL OF NURSES (ICN)

A. Purpose: to provide a medium through which national nursing associations can work together and share common interests; formed in 1899

Focus topic: Legal Aspects of Nursing

B. Functions

  • Serves as representatives of and spokespersons for nurses at international level.
  • Promotes organization of national nurses’ associations.
  • Assists national organizations to develop and improve services for public health practice of nursing and social/economic welfare of nurses.

II. WORLD HEALTH ORGANIZATION (WHO)— special intergovernmental agency of the United Nations, formed in 1948

A. Purpose: to bring all people to the highest possible level of health

B. Functions: provides assistance in the form of education, training, improving health standards, fighting disease, and reducing water pollution in member countries

III. AMERICAN NURSES ASSOCIATION (ANA)— national professional association in the United States, composed of the nurses’ associations of the 50 states, Guam, Virgin Islands, Puerto Rico, and Washington, DC

A. Purpose: to foster high standards of nursing practice and promote the education and welfare of nurses

B. Functions: officially represents professional nurses in the United States and internationally; defines practice of nursing; lobbies and promotes legislation affecting nurses’ welfare and practice

IV. NATIONAL LEAGUE FOR NURSING (NLN)— composed of both individuals and agencies

A. Purpose: to foster the development and improvement of all nursing services and nursing education

B. Functions

  • Provides educational workshops.
  • Assists in recruitment for nursing programs.
  • Provides testing services for both RN and LPN (LVN) nursing programs.

Legal Aspects of Nursing: SAFETY AND INFECTION CONTROL: GUIDELINES FOR ISOLATION AND STANDARD PRECAUTIONS

Focus topic: Legal Aspects of Nursing

A key component of the NCLEX-RN® test plan is injury prevention in the provision of a safe environment. This section also identifies potential risks to child safety with recommendations for a child-safe environment.

I. GUIDELINES FOR ISOLATION AND INFECTION CONTROL

Focus topic: Legal Aspects of Nursing

A. Guidelines for Isolation Precautions

B. Contact Precautions—Summary

C. Standard Precautions—Summary

D. Airborne and Droplet Precautions—Summary

E. Infection Control by Clinical Syndrome/Condition

F. Infection Control When Caring for Infants, Children, and Adolescents

G. Summary: Types of Precautions and Illnesses Requiring the Precautions

II. GUIDELINES FOR ENVIRONMENTAL SAFETY

Focus topic: Legal Aspects of Nursing

A. Safety Considerations When Caring for Hospitalized Infants, Children, and Adolescents

B. Safety and Injury Prevention—Home Safety

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