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Chapter 3
Introduction to Medical-Surgical Nursing
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
1
Ethics
Values relevant to human conduct
Defines what actions are right and
wrong and whether the motives and
outcomes of those actions are good or
bad
Choices are often shades of gray, not
black and white, or a choice must be
made between two good or two bad
options
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
2
Ethical Dilemmas
 Ethics does not prescribe one right answer
 Define formal processes to explore what is proper
conduct
 Bioethics
 Ethical questions that arise in the context of
health care
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
3
Ethical Dilemmas cont’d
 Morality
 Shared ideas of what is right or good within a society or
culture
 Moral distress
 Occurs when nurse feels powerless because his/her
moral beliefs cannot be followed because of institutional
or other barriers
 One reason that some nurses leave nursing
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
4
Ethical Dilemmas
 Moral outrage
 May occur when another person in the health care
setting acts in a way that the nurse believes is immoral
and the nurse feels powerless to intervene
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
5
Principles of Ethics
 Autonomy
 Recognition is inherent in the concept of informed
consent and in advance directives
 Respect for the rights of people to make decisions about
their own health and health care, such as accepting or
refusing blood transfusions or medications
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
6
Principles of Ethics
cont’d
 Beneficence
 Actions to promote good, prevent harm, or remove the
patient from harm
 Nurse behaves in the patient’s best interest
 The problem is to define good, recognizing that the
definitions of the patient, the family, the nurse, and the
physician may differ
 An example of preventing harm is reporting a
co-worker who is impaired or incompetent
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
7
Principles of Ethics
cont’d
 Justice
 Fairness, equity, appropriateness of treatment
 Recognition that goods and services are limited
 Decisions about who will receive limited resources are
based on various philosophies and might use the criteria
of equal distribution; individual need, merit, social
contribution, rights, or effort; or serving the greatest
good for the greatest number of individuals
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
8
Principles of Ethics
cont’d
 Nonmaleficence
 Requires that the nurse “do no harm”
 Therapeutic interventions can be uncomfortable; benefits
must justify the discomfort
 A patient getting out of bed for the first time after surgery
likely will experience some pain, but the benefits of
mobilization far outweigh temporary discomfort
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
9
Principles of Ethics
cont’d
 Confidentiality
 Patient information must be protected
 Patients have the right to control who has access to
personal information
 Nurses must guard against the careless, accidental, or
deliberate sharing of private information
 Veracity (truth)
 Nurses must be honest with patients as well as in
documentation and communication with colleagues
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
10
Values
 Beliefs and attitudes important to a person that
influence daily choices
 Result of cultural, social, and personal experiences
 Family is foundation for values formation
 Values essential for professional nurses: altruism,
equality, aesthetics, freedom, human dignity, justice,
and truth
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
11
Values cont’d
 Values conflicts
 Values of individuals and institutions are different
 Risk that patient’s values may not be recognized or
respected
 As a nurse, you can recognize values conflicts by being
aware of your own values and learning about those of
your patients
 Try to understand the other person’s views and find
common ground
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
12
Philosophical Basis of Ethics
 Feminist ethics
 Inequalities between people on the basis of gender; also
places value on relationships
 Ethics of care
 Care is a “central activity of human behavior and one
that deserves special attention in health care”
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
13
Steps in Processing Ethical Dilemmas
 Determine that it is an ethical problem
 Ethical problems have all of the following characteristics
 Scientific information does not provide the answer
 The problem is perplexing, i.e., the answer is not simple
 The solution is profoundly relevant to several areas of
human concern
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
14
Institutional Ethics
Committees
 Most institutions have committees to process ethical
dilemmas
 Multidisciplinary membership seeks input from
patients, families, professionals, administrators
 Functions of the ethics committee: education, policy
recommendation, oversight of policy implementation,
consultation on specific cases
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
15
Legal Implications for Nursing
Practice
 Law defines the boundaries of nursing practice
 Nurses must know their functions and limitations in
order to protect their patients and themselves
 A nursing license is granted only to those who have
met specific educational standards and demonstrated
the minimal required level of knowledge as assessed
by an examination
 The state board of nursing can revoke or suspend the
license of a nurse who violates the provisions of the
licensing statutes
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
16
Types of Law: Statutory
Laws
Created by elected legislative bodies,
including nurse practice acts
Classified as either civil or criminal
Criminal laws are concerned with
preventing harm to society or punishing
violators
Civil laws protect individual rights
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
17
Types of Law:
Regulatory Laws
Created by administrative bodies, such
as state boards of nursing
Rules and regulations that address the
conduct of nurses
Common law
Result of judicial decisions made when
individual cases are decided in the courts
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
18
Types of Law: Tort
 A tort is a civil wrong against a person or property
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Types of Law: Intentional
Tort
Assault
Contact without the patient’s consent
Battery
Touching in an offensive or harmful manner
without consent
Invasion of privacy
Unwanted intrusion into the patient’s private
affairs
Defamation of character
Releasing information that could damage a
person’s reputation
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Types of Law:
Unintentional Tort
 Negligence
 Conduct that falls below the standard of care
 Malpractice
 Professional negligence
 To be found liable, it must be shown that the nurse owed
a duty to the patient, the nurse did not carry out that
duty, the patient was injured, and the injury was caused
by the nurse’s failure to carry out
the duty
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
21
Types of Law: Unintentional
Tort cont’d
 Nurse’s best protection against charges of negligence
and malpractice
 Adhere to standards of care; provide competent care;
communicate with other members of the health care
team; fully document assessments, interventions, and
evaluations; and establish good relations with patients
 Student nurses are held to the same standards of care
as are licensed nurses
 Students should never perform care for which they have
not been prepared
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
22
Malpractice Insurance
 Health care institutions commonly provide
malpractice insurance for nurses they employ
 Covers legal fees and awards if nurse is sued for
professional negligence or medical malpractice
 If the act in question occurs outside place of
employment, the agency insurance does not cover the
nurse
 Nurses need to decide whether to carry personal liability
insurance as well
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Malpractice Insurance
cont’d
 At times, nurses assist at accident scenes. As long as
actions are within accepted standards, Good Samaritan
laws protect them from liability
 State laws vary; nurses should acquaint themselves with
the laws in their states of residence
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Confidentiality
 Every patient’s right: medical diagnoses and treatment
must be kept confidential
 Protect the privacy of patient records and avoid public
discussion of patient information
 Never copy/remove any part of a patient’s record
 HIPAA laws of 2003 made health care providers
acutely aware of the actions needed to protect patient
confidentiality
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
25
Consent
 Patients have the right to make decisions about their
own care; caregivers may not impose care against a
patient’s wishes
 Informed consent
 Provide sufficient information for the patient to make an
informed decision
 Elements of informed consent: patient decision-making
capacity, sufficient information, and voluntary agreement
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
26
Consent cont’d
 State law defines who can give consent for minors and
people incapable of making their own decisions
 A confused or sedated person cannot give consent even
if usually capable of making decisions
 Signatures on consent forms must be obtained before
administering preoperative medications
 Consent must be voluntary
 There can be no real or implied coercion
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Consent cont’d
 Required for hospital admission, surgery, some
treatments, and research participation
 Physician is responsible for obtaining informed consent
 Nurses may obtain patient signatures and serve as
witnesses to the signature per agency policy
 If the nurse suspects the patient lacks
decision-making capacity or does not fully understand
the implications of the consent form, the physician
should be contacted and the supervisor notified
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
28
Physician Orders
 Legal, appropriate orders should be carried out
 If nurse believes an order is inappropriate, physician
should be contacted for confirmation or correction
 If physician confirms order and LVN/LPN still
believes it is inappropriate, the nurse should contact
the supervisor to intervene
 Nurse may share responsibility for harm that follows
implementation of an inappropriate order
 Verbal orders increase the risk for error; follow agency
policy
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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DNR (Do Not
Resuscitate) Orders
 Resuscitation will not be initiated if a patient ceases to
breathe or the heart stops
 Orders should be written and reviewed regularly in
case patient’s status changes
 In many states, in the absence of a written order, it is
assumed that resuscitation is appropriate
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Short Staffing
 Staffing inadequate for competent care
 The supervisor should be notified
 Written protest submitted when required to accept an
assignment without adequate staffing
 Nurses should know their state regulations and agency
policies for such situations
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Short Staffing: Patient Abandonment
 Walking out or refusing an assignment could be
viewed as patient abandonment
 Includes sleeping on the job, leaving in the middle of a
shift without notifying anyone, failing to show up or
complete an agreed assignment in a home setting, and
leaving the patient care area and remaining
unavailable such that patient safety may be
compromised
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Short Staffing: Safe
Harbor
 A nurse may be able to invoke “safe harbor” if given
an assignment that the nurse believes violates his or
her duty to the patient
 Protects nurses from actions against their license when
they notify the supervisor at the time the assignment is
made
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Floating
 Nurses are obligated to inform supervisors if they lack
the skill to care for particular patients
 Nurses who float to new units must be oriented to the
setting and trained for the new area
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Right to Refuse
Treatment
 Patients have the right to refuse medical treatment,
including life-sustaining care
 When a patient is incompetent to make his or her own
decisions, an effort is made to determine what the
person would have wanted
 Advance directives help define the patient’s wishes
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Nurse Practice Act

 Nursing is a specific profession that has legal
definitions as to scope or boundaries of practice.
 The law that defines and regulates the practice of
nursing in the United States is the Nurse Practice
Act.
 Laws are written by the legislature of each state.
 Go to www.msbn.ms.gov
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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
 The legislative power to initiate, regulate, and
enforce the provisions of the Nurse Practice Act is
delegated to the State Board of Nursing
 The National Council of State Board of Nursing is
responsible for the NCLEX exam.
 Revoking a License
Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc.
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Good Samaritan Act

 A law that protects individuals from liability if they
give emergency care within the limits of first aid and
if the individual acts in a reasonable and prudent
manner.
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