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Chapter 3
Introduction to Medical-Surgical Nursing
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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”
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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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