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CHAIR PERSON
DR.K.LALITHA
PROFESSOR & HOD
DEPARTMENT OF NURSING
NIMHANS
PRESENTER
JINTO PHILIP
I MSc PSYCHIATRIC NURSING
NIMHANS
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biological, psychological and social stresses and challenges throughout the life
while continuing to maintain a sense of well-being.
Nurse: Nurse is a person who has completed prescribed course in Nursing from an institution
recognized by Indian Nursing Council and registered herself/himself under the State Nursing council as
Nurse and midwife.
Nursing: Nursing is a professional service for enabling a person to maintain and sustain health and
wellbeing.
Performance criteria: Selected behaviors which illustrate how the standard is achieved.
Practice standards: Set of Activities expected from professional group of workers.
Personal etiquettes: Being polite & soft spoken, honest, sincere, cheerful, dignified, affectionate,
compassionate and courteous.
Professional etiquettes: Being attentive listener, keen observer, objective, non-judgmental,
empathetic, confident, assertive, disciplined, prompt and efficient.
Professional body or Regulatory body: Indian Nursing Council / State Nursing Council is statutory
body which regulates the Nursing Education and practice in India.
Professional Worker: A person who confirms to a level of practice that is expert and ethical after
completing an authorized educational programme.
Provider: Same as nurse
Quality Nursing Practice: Quality of nursing practice is achieved when organizations processes and
activities are designed and implemented to meet the needs and expectations of the receiver on a
competent, consistent and continuous basis.
Quality Assurance in Nursing: Quality Assurance is a program for formal guarantee for provision of
quality nursing care against set standards.
Rationale: Reasoning for the standards.
Receiver: Receiver(s) refer to those individual persons/ families/ groups/ communities who are in
need of assistance from Nurse to maintain and sustain their health and well-being.
Standards: Level of performance required for obtaining a specified desired outcome.
Vulnerable: vulnerable persons are those who are disadvantaged due to physical, emotional and social
and economic reasons e.g.,
Well Being: It is an active state of a person with maximum potential by maintaining balance and is at
peace with inner and outer world.
ETHICAL & LEGAL CONSIDERATIONS IN NURSING
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2. The nurse respects the rights of individuals as partner in care and helps in making informed
choices
Nurse
2.1 Appreciates individuals right to make decisions about their care and therefore gives
adequate and accurate information for enabling them to make informed choices.
2.2 Respects the decisions made by individual (s) regarding their care.
2.3 Protects public from misinformation and misinterpretations.
2.4 Advocates special provisions to protect vulnerable individuals/groups.
3. The nurse respects individuals right to privacy, maintains confidentiality, and shares
information judiciously.
Nurse
3.1 Respects the individuals right to privacy of their personal information.
3.2 Maintains confidentiality of privileged information except in life threatening situations and
uses discretion in sharing information.
3.3 Takes informed consent and maintains anonymity when information is required for quality
assurance/academic/legal reasons.
3.4 Limits the access to all personal records written and computerized to authorized persons
only.
4. Nurse maintains competence in order to render Quality Nursing Care
4.1 Nursing care must be provided only by registered nurse.
4.2 Nurse strives to maintain quality nursing care and upholds the standards of care.
4.3 Nurse values continuing education, initiates and utilizes all opportunities for self
development.
4.4 Nurse values research as a means of development of nursing profession and participates in
nursing research adhering to ethical principles.
5. The nurse is obliged to practice within the framework of ethical, professional and legal
boundaries
Nurse
5.1 Adheres to code of ethics and code of professional conduct for nurses in India developed by
Indian Nursing council.
5.2 Familiarizes with relevant laws and practices in accordance with the law of the state.
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6. Nurse is obliged to work harmoniously with the members of the health team.
Nurse
6.1 Appreciates the team efforts in rendering care.
6.2 Cooperates, coordinates and collaborates with the members of the health team to meet the
needs of the people.
7. Nurse commits to reciprocate the trust invested in nursing profession by society
Nurse
7.1 Demonstrates personal etiquettes in all dealings.
7.2 Demonstrates professional attributes in all dealings.
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2.4 Presents realistic picture truthfully in all situations for facilitating autonomous decisionmaking by individuals and families
2.5 Promotes participation of individuals and significant others in the care
2.6 Ensures safe practice
2.7 Consults, coordinates, collaborates and follows up appropriately when individuals care
needs exceed the nurses competence.
3. Communication and Interpersonal Relationships
Nurse
3.1 Establishes and maintains effective interpersonal relationship with individuals, families and
communities
3.2 Upholds the dignity of team members and maintains effective interpersonal relationship
with them
3.3 Appreciates and nurtures professional role of team members
3.4 Cooperates with other health professionals to meet the needs of the individuals, families and
communities
4. Valuing Human Being
Nurse
4.1 Takes appropriate action to protect individuals from harmful unethical practice
4.2 Consider relevant facts while taking conscience decisions in the best interest of individuals
4.3 Encourage and support individuals in their right to speak for themselves on issues affecting
their health and welfare
4.4 Respects and supports choices made by individuals
5. Management
Nurse
5.1 Ensures appropriate allocation and utilization of available resources
5.2 Participates in supervision and education of students and other formal care providers
5.3 Uses judgment in relation to individual competence while accepting and delegating
responsibility
5.4 Facilitates conducive work culture in order to achieve institutional objectives
5.5 Communicates effectively following appropriate channels of communication
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6. Professional Advancement
Nurse
6.1 Ensures the protection of the human rights while pursuing the advancement of knowledge
6.2 Contributes to the development
6.3 Participates in determining and implementing quality care
6.4 Takes responsibility for updating own knowledge and competencies
6.5 Contributes to the core of professional knowledge by conducting and participating in
research
Autonomy
The term autonomy comes from the Greek word autos (meaning self) and nomos (meaning
rule, governance or law). I.e. autonomy means self-governing or right to make ones own
decisions. In contemporary discourse it has broad meanings, including individual rights, privacy, and
choice. Autonomy entails the ability to make a choice free from external constraints.
Autonomy basically mean that people should be free to choose and entitled to act on their
preferences provided their decisions and actions do not stand to violate or impinge on, the significant
moral interest of others. Nurses who follow this principle recognize that each client is unique, has the
right to be what that person is, and has the right to choose personal goals. Honoring the principle of
autonomy means that the nurse respects a clients right to make decisions even when those choices
seems not to be in the clients best interest. Adults with capacity (physical and mental) to make
healthcare decisions have the right to consent to or refuse treatment. Even if healthcare providers do
not agree with a clients decision, they must respect the clients wishes (Beauchamp & Childress, 2001).
Infants, young children, people who are severely mentally handicapped or incapacitated, and people in
a persistent vegetative stage or coma do not have the capacity to participate indecision making about
their healthcare. For such people, a surrogate decision maker must be identified to act on their behalf.2
National League of Nursing Statement on Patients' Rights
To health care that is accessible and that meets professional standards, regardless of the setting.
To courteous and individualized health care that is equitable, humane, and given without
discrimination as to race, color, creed, sex, national origin, source of payment, or ethical or
political beliefs.
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To information about their diagnosis, prognosis, and treatment including alternatives to care
and risks involved in terms they and their families can readily understand, so that they can give
their informed consent.
To informed participation in all decisions concerning their health care.
To information about the qualifications, names, and titles of personnel responsible for providing
their health care.
To refuse observation by those not directly involved in their care.
To privacy during interview, examination, and treatment.
To privacy in communicating and visiting with people of their choice.
To refuse treatment, medications, or participation in research and experimentation, without
punitive action being taken against them.
To coordination and continuity of health care.
To appropriate instruction or education from health care personnel so that they can achieve an
optimal level of wellness and an understanding of their basic health needs.
To confidentiality of all records (except as otherwise provided for by law or third party payer
contracts) and communications, written or oral, between patients and health care providers.
To access to all health records pertaining to them, and the right to challenge and correct their
records for accuracy, and the right to transfer all such records in the case of continuing care.
To information on the charges for services, including the right to challenge these.
To be fully informed as to all their rights in all health care settings.4
Accountability
Accountability is the obligation of being answerable for one's own judgments and actions to an
appropriate person or authority recognized as having the right to demand information and
explanation. (A dictionary of nursing, 2008)
Integral to the practice of any profession is the inherent need to be responsible for actions taken
and for omissions.
The professional nurse must be proactive and take all appropriate measures to ensure that her
own practice is not lacking, remiss, or deficient in any area or way.
Useful proactive measures include:
o Maintaining familiarity of relevant, current hospital policies, procedures, and regulations
as they apply to the nurse's practice and specialty area.
o Providing for self-audit.
o Providing for peer review to assess reasonableness of care in a particular setting for a
particular problem.
o Working with local nursing organizations to make certain that local standards of practice
are met.
o Examining the quality (accuracy and completeness) of documentation.
o Establishing open working relationships with colleagues wherein honest constructive
criticism is welcomed for the greater goal of quality patient care.
Local standards of practice normally coordinate with those of nationally accepted standards.
Assertiveness
Assertiveness is the quality or state of bold or confident self-expression, neither aggressive nor
submissive (Dorlands medical dictionary, 2007)
Assertiveness is the ability to express yourself and your rights without violating the rights of
others
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It means that we have respect both for ourselves and for others. We are consciously working toward
a "win-win" solution to problems. A win-win solution means that we are trying to make sure that
both parties end up with their needs met to the degree possible. An assertive person effectively
influences, listens, and negotiates so that others choose to cooperate willingly.
Specific Techniques for being Assertive
*Be as specific and clear as possible about what you want, think, and feel. The following statements
project this preciseness:
a. "I want to..."
b. "I don't want you to...
*Allow others to complete their thoughts before you speak.
* Make your own decisions based on what you think is right
* Look to friendships as opportunities to learn more about yourself and others and to share ideas.
* Spontaneously and naturally enter into conversations using a moderate tone and reasonable volume
of voice.
* Try to understand the feelings of others before describing your own.
* Try to avoid harm and inconvenience by talking out your problems before they occur or finding
rational means for coping with unavoidable harm or inconvenience.
* Face problems and decisions squarely.
* Consider yourself strong and capable, but generally equal to most other people.
* Face responsibility with respect to your situation, needs and rights.
On being Non-assertive
* Stay in the back of groups.
* Always stick to the middle-of-the road position.
* Allow others to make decisions for you.
* Always keep your voice low or avoid eye contact to keep from calling attention to yourself
* Verbally agree with others despite your real feelings.
* Bring harm or inconvenience to yourself to avoid harming or inconveniencing others.
* Procrastinate to avoid problems and to keep from making decisions.
ETHICAL & LEGAL CONSIDERATIONS IN NURSING
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It assists in maintaining a standard of nursing practice by making nurses accountable under the
law.
Sources of Laws
Three kinds of laws have the potential to affect nursing practice:
Civil law generally governs actions by one individual or corporation against another. E.g. A client
or family member sues the nurse or nurses employer for malpractice because of a claim of client
injury caused by nursing care.
Criminal law involves actions by the state against an individual by the state against an individual
for violations of criminal statutes. E.g. drug diversion, client assault, mercy killing etc.
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To provide adequate supervision and evaluation of others for whom the nurse is
responsible.
To remain competent.
Rights:
Right to adequate and qualified assistance as necessary.
Right to reasonable and prudent conduct from clients, e.g., provision of accurate
information as required.
Role-Employee or contractor for service
Responsibilities:
To fulfill the obligations of contracted service with the employer.
To respect the employer.
To respect the rights and responsibilities of other health care providers.
Rights:
Right to adequate working conditions (e.g. safe equipment and facilities)
Right to compensation for services rendered.
Right to reasonable and prudent conduct by other health care providers.
Role-citizen
Responsibilities:
To protect the rights of the recipients of care.
Rights:
Right to respect by others of the nurses own rights and responsibilities.
Right to physical safety.
Standards of care
Informed consent
Informed consent is an agreement by a client to accept a course of treatment or a procedure after
complete information, including the risks of the treatment and facts relating to it , has been provided by
a health care professional
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The doctrine of informed consent has become a fundamentally accepted principle governing the
relationship between professional nurses and all other health care providers and patients.
Informed consent relates to the patient's right to accept or reject treatment by a nurse or any
other health care provider and is a right of all legally competent adults or emancipated minors.
In the majority of circumstances, informed consent is obtained for medical or surgical
procedures to be performed by physicians. Therefore, the duty to inform the patient of
alternative treatments, the nature of the procedure, the benefits, and potential risks is the
physician's. Oftentimes, especially when the patient is hospitalized, the nurse is required to
witness the patient's signature before the procedure. It is prudent for the nurse to note witness
to signature directly next to the patient's signature.
Emancipated minors are individuals who are under age 18 and married, or are parents of their
own children, or are self-sufficiently living away from the family domicile with parental consent.
In the case of a minor, informed consent would be obtained from the legal guardian.
In the case of individuals incapable of understanding medical treatment issues, informed
consent must be obtained through a responsible person such as a guardian.
The nurse has the duty to verify that the physician or other health care provider has explained
each treatment or procedure in a language the patient (or the responsible person) can
comprehend, that he has warned the patient of any material risks, dangers, or harms inherent in
or collateral to the treatment, and has advised the patient of available alternatives. This enables
the patient to make an intelligent and informed decision and choice about whether to undergo
treatment.
The informed consent should be obtained before rendering the treatment or performance of the
procedure.
The nurse must document that the informed consent was obtained and that the patient
understood the information.
The informed consent should be obtained in the presence of a witness.5
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Defamation: is communication that is false, or made with a careless disregard of the truth, and
results in injury to the reputation of the person.
Fraud: fraud is the willful, purposeful misinterpretation of self or an act that may cause harm to
a person or property.
Invasion of privacy: disclosing confidential information to an inappropriate third party subjects
the nurse to liability for invasion of privacy, even the information is true.
False imprisonment: prevention of movement or unjustified retention of a person without
consent may be false imprisonment.
Legal protection in nursing practice
Good Samaritan Acts
Good Samaritan acts are laws designed to protect healthcare providers who provide assistance
at the scene of an emergency against the claims of malpractice unless it can be shown that here was a
gross departure from the normal standards of care or willful wrongdoing on their part.
Guidelines for nurses who choose to render emergency care are:
Limit actions to those normally considered first aid as possible.
Do not perform actions that you do not know how to do.
Offer assistance, but do not insist.
Do not leave the scene until the injured person leaves or another qualified person takes over.6
Legal precautions for Nurses
Function within the scope of your education, job description and area of nursing practice.
Follow the procedures and policies of the employing agency.
Build and maintain good rapport with the clients.
Always identify the clients, particularly before initiating major interventions.
Observe and monitor the client accurately. Communicate and record significant changes.
Promptly and accurately document all the assessment and care given.
Be alert when implementing nursing interventions and give each task your full attention and
skill.
Perform procedures appropriately.
Follow 5 rights while administering medications.
ETHICAL & LEGAL CONSIDERATIONS IN NURSING
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When delegating responsibilities, make sure that the person who is delegated a task
understands what to do and that the person has the required knowledge and skill.
Protect clients from injury.
Report all incidents involving clients.
Always check any order that a client questions and ensure that verbal orders are accurate and
documented appropriately.
Know your strengths and weaknesses.
Maintain your clinical competence.
Conclusion
Addressing ethical problems in clinical practice is a moral obligation that fosters empowerment for all
nurses. It increases the nurses satisfaction about what they can achieve for the clients to whom they
provide care. Nurses achieve personal and professional success by identifying ethical problems and
legal responsibilities in clinical practice and using their knowledge skills to bring about resolution. 6
BIBLIOGRAPHY
1. Code of Ethics and Professional Conduct. Indian Nursing Council. New Delhi. Page 1-17
2.
Ford Gary G. Ethical Reasoning for Mental Health Professionals. New Delhi: Sage
Publications;2006.Page 1-13
3. Johnstone, Megan- Jane. Bioethics: A Nursing Perspective. 4TH edition. Australia:Elsevier;2004. Page
18-46
4. Kozier, Erb, Berman, Burke. Fundamentals of Nursing: Concepts, Process and Practice.6 TH edition.
Singapore: Pearson Education (Pte.Ltd); 2003.Page 70-83
5. Pattricia.A.Potter, Anne Griffin Perry, Moshy. Basic Nursing:Essentials for Practice. 6TH edition.
St.Louis,Missouri: Elsevier;2008. Page 67-70
6. Ruth F. Craven, Constance J. Hirnle. Fundamentals of Nursing: Human Health and Function.5 TH
edition. Philadelphia: Lippincott Williams & Wilkins; 2007. Page 87-106
7. www.en.wikipedia.org/wiki/Assertiveness
8. www.encyclopedia.com
9. www.medical-dictionary.thefreedictionary.com/assertive
10. www3.interscience.wiley.com/journal/119304526/abstract?CRETRY=1&SRETRY=0
11. www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692007000200002
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