1

Legal Ethical Aspect

in Nursing

Lecture No.12
Learning Outcomes
After completing this chapter, students will be able to:
1. Describe ways nurse practice acts, credentialing, and standards of care
affect the scope of nursing practice.
2. Describe the purpose and essential elements of informed consent.
3. Discuss substance use disorder (SUD) in nursing
4. Discriminate between negligence and professional negligence or
malpractice.
5. Compare and contrast intentional torts (assault and battery, false
imprisonment, invasion of privacy) and unintentional torts (professional
negligence).
6. Discuss the legal responsibilities of nursing students.
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 Legal Aspects of Nursing
 Nursing practice is governed by many legal concepts.

It is important for nurses to know the basics of legal concepts, because:-
Nurses are accountable for their professional judgments and actions.
To ensure that the nurse’s decisions and actions are consistent with current
legal principles.
 To protect the nurse from liability.

Law is a body of rules and regulations by which a society is governed & guide
human functions.
 Regulation of Nursing Practice
Nurse Practice Acts
• Define the scope of practice.
• Set boundaries for safe practice.
Nurses who know and follow their nurse practice act provide safe, competent nursing care.

Credentialing
• Licensure – legal authorization; ensures minimum competence.
• Certification – specialty competence.
• Accreditation – ensures quality programs.

Standards of Care
• Reflect on commonly expected nursing skills.
• Internal: job descriptions, policies. External: ANA, specialty orgs, regulations.
 Selected Legal Aspects of Nursing Practice

Nurses need to know and apply legal aspects in their many

different roles.
1. Informed Consent
2. Delegation
3. Violence, Abuse, and Neglect
4. Controlled Substances & Substance Use Disorder (SUD)
5. Sexual Harassment
6. Death & related issues (DNR & Euthanasia)
 [Link] Consent
Informed consent is a client's agreement to accept a course of treatment or procedure after
being provided with complete information, including the benefits and risks of the treatment,
alternatives to the treatment, and the prognosis if not treated.
 Informed Consent Exception
• Three groups of people cannot provide consent:
1.A minor, a person 18 years or younger
[Link] unconscious or person injured in such a way that they are unable to consent
3.A mentally ill person judged by a professional to be incompetent.
Types of Consent
• Express: written or verbal.
• Implied: behavior indicates agreement.
• Emergency: assumed when no surrogate is available.
Elements of Valid Consent
• Voluntary decision (client must not feel coerced )
• Competent individual (capacity to understand)
• Adequate information provided.
Nurse’s Role in an informed consent
• Witness signature.
• Ensure voluntariness.
• Confirm patient understanding.
• Signature is authentic ( client appears competent)
• Client has right to refuse even after signing consent form
• Documentation
2. Delegation
• “The process for a nurse to direct another
person to perform nursing tasks &
activities”
• It is important to the nurse to know that
the responsibility for action on the part of
the nurse remain with the nurse.

• Example: Delegating vital signs to

assistant is appropriate; medication
admin is not.
3. Violence, Abuse, and Neglect
Violent behavior can include domestic violence, child abuse, abuse of
older adults, and sexual abuse.

Neglect is the absence of care necessary to maintain the health and

safety of a vulnerable individual, such as a child or older adult.

Nurses can often identify and assess cases of violence against others.

 Nurses are often considered mandated reporters, meaning that the

law requires them to report suspected abuse, neglect, or exploitation
‫استغالل‬.

Example: Child with repeated bruises → nurse must report suspicion.

4. Controlled Substances & Substance Use Disorder (SUD)

Substance use disorder (SUD) involves a pattern of behaviors ranging from misuse to
dependency or addiction to alcohol or drugs.
Nurses can be at increased risk because of the high levels of stress involved in many
healthcare settings and the easy access to drugs.
The nurse needs to know the proper reporting procedures for nurses whose practice is
affected by SUD.
 Controlled substances: Strict handling rules; misuse = legal penalty.
 Goal: recovery, not punishment.
 Look for behavior, physical signs, drug diversion.
 Report to supervisor ethically and professionally.
 Example: Narcotics must be double-checked and documented. Nurses must follow
documentation procedures.
5. Sexual Harassment
Unwelcome verbal or physical conduct.
Know institutional policies.
Example: Repeated inappropriate comments from
coworker = harassment.

 If the Nurse is a victim of sexual harassment, the

ANA suggests 4-Tactics:
(1) Confront the harasser
(2) Report to the supervisor (file a formal complaint)
(3) Document the incident (name any witnesses)
(4) Seek support from friends, family, and
organizations (such as the ANA)
6. Death and Related Issues
Do Not Resuscitate (DNR Orders) = no CPR during arrest; Allow Natural Death
(AND) terminology.
Nurses must respect & follow orders.
Example: Nurse must not initiate CPR if valid DNR present.
A DNR Permits health care providers to withhold ONLY treatment related to
resuscitation. Does not apply to withholding nourishment; hydration; or IVF’s

Euthanasia ‫القتل الرحيم‬

Illegal in Jordan.
Active euthanasia is illegal; withholding or withdrawal useless treatment is
allowed.
Example: Turning off ventilator per patient wishes ≠ euthanasia.
Provider of service – safe care.
 Areas of Potential Liability in Nursing
Nursing liability is usually involved with tort law.

Torts are classified as negligence (unintentional or intentional)

• Unintentional Torts: These types of torts are accidents that course injury to another person
or property (Negligence & Malpractice).

• Intentional Torts
 Unintentional Torts: Negligence vs Malpractice
• Negligence: failure to meet standard of care.
• Malpractice: professional negligence.
• Requires all legal elements present.
• Example: Not raising bed rails → patient falls → negligence.
4 elements of negligence
Duty to act (Nurse – Patient relationship)
Breach of duty (SOC not followed - reasonably prudent nurse)
Damage (Physical & Psychological) No damage no case!
Causal connection (close connection between nurses conduct & injury)
All 4 must be proven
Malpractice-Professional Negligence ‫اإلهمال المهني‬
 Failure to use equipment in a responsible manner
 Failure to assess and monitor, and failure to report changes
 Failure to document
 Failure to act as a patient advocate
 Performing nursing procedures incorrectly
 Failing to take appropriate precautions
 Medication errors.
 Incorrect patient identification.
 Ways to Avoid Malpractice

Know your own strengths and weaknesses

Evaluate your assignment
Delegate carefully
Document
Take steps to prevent falls
Follow hospital policies and procedures
Keep policies and procedures up to date
Provide a safe environment
Intentional Torts
 Inintentional torts, the defendant committed the act with intent.
 As an example of intentional torts related to nursing:-
• Assault
• Battery
• False imprisonment.
• Invasion of privacy.

Lecture No.13
Assault & Battery ‫االعتداء والبطش‬
• Assault is an act that results in a person’s
genuine fear and apprehension that he or she will
be touched without consent (threat)
• Battery is the touching of another person without
consent (actual touching)
• These charges can result when a treatment is
administered to a client against his or her wishes
and outside of an emergency situation.
• Liability applies even though the primary care
provider ordered the medication or the activity
and even if the client benefits from the nurse’s
action.
• Example: Nurse gives injection without consent.
• Even if beneficial → still battery.
False imprisonment ‫الحجز غير القانوني‬

• False imprisonment is the deliberate and

unauthorized confinement of a person within
fixed limits by the use of verbal or physical
means (prevents the patient from
leaving).

• Health care workers may be charged with

false imprisonment for restraining or
secluding —against the wishes of the
client—Must allow AWA (absence without
authority) or AMA (against medical advice)
form.
Invasion of Privacy:‫انتهاك الخصوصية‬

• Sharing client info without consent.

• Discussing the case in public areas.
• Posting anything identifiable online.
• Computerized charting: Protect
password security & don’t forget to
log off

• Example: Discussing patient details

in the elevator violates privacy.
Privacy of Clients’ Health Information-Patient
confidentiality
Never leave paper chart/computer screen in a public place

Discuss contents only with persons directly involved in patient’s care or those
authorized by the patient. They should be listed by name. (Don’t assume
partners have access to information)
Ask for ID prior to providing information
Do not discuss pt or pts info in public, places, elevators, cafeteria, or at parties.
Don’t view patient’s information not in your care: family;
friends; celebrities and etc.
 Loss of Client Property

• Follow policy for valuables.

• Document handling of items.
• Nurse may be liable for loss.
 Avoiding Liability & Legal Protections

Suggest the following proactive nursing actions in an effort to avoid nursing

malpractice:
● Professional liability Insurance covers legal defense
● Clarify physician orders if ambiguous or unsafe & report condition changes
● Providing competent practice & complying with the standard of care
● Documentation
● Incidence Report.
Incident Reports
 Should be completed for any usual, unexpected, or unanticipated
occurrences, and for any event which has or may have an adverse patient
outcome (e,g: Patient falls; Medication error; Equipment malfunction)

 Be Objective: Describe facts only (What did you do)

 Do not blame
 Do not include names/addresses of witnesses
 Document time/name of medical provider
 Notify risk management
 Used for quality improvement; not part of the medical chart.
 Do not write “incident report made”
 Legal Responsibilities of Students

• Must seek supervision.

• Cannot perform advanced skills alone.
• Students are liable for their actions.
• Follow institutional policies.
• Students held to RN standards during procedures.
• Example: Student administers wrong medication dose (Student +
supervising nurse legally responsible).
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6

Values, Ethics, and

Advocacy
Learning Outcomes
After completing this chapter, students will be able to:

1. Explain how values, morals, and codes of ethics affect moral

decisions.
2. Explain how nurses use knowledge of values to make ethical
decisions
3. Identify the moral issues and principles involved.
4. Discuss common ethical issues currently facing healthcare
professionals.
5. Discuss the advocacy role of the nurse. 27
 Ethics, Moral & Values
 Ethics is the science that deals with the rightness and wrongness of actions

 Bioethics is the term applied to these principles when they refer to concepts within the scope
of medicine, nursing, and allied health.

 Moral behavior: how individuals ought to treat others. Moral behavior reflects the way a
person interprets basic respect for other persons

 Values: are ideals or concepts that give meaning to the individual’s life, influence behavior &
decisions. Example: A nurse valuing dignity ensures privacy during care.
• Personal Values from culture; professional values from nursing training.
• Example: A Nurse may oppose abortion personally, but still must provide unbiased care.
• Values clarification is important in nursing to increase understanding about why certain
choices and decisions are made over others and how values affect nursing outcomes.
 Ethics and Morality
• Ethics = professional standards.
• Morals = personal beliefs.
• They must decide the morality (standards of right
and wrong) of their own actions when they face the
many ethical issues that surround such sensitive
areas.
• Laws reflect a society’s moral values and offer
guidance in determining what is moral.
• Action can be legal but not moral.
• For example, an order for full resuscitation of a dying
client is legal, but one could still question whether the
act is moral.
 Case: Ethical Dilemma

An ethical dilemma is a situation that requires an individual to make

a choice between two equally unfavorable alternatives (Catalano,
2006).
•Terminal client refuses feeding tube.
•Nurse supports autonomy.
•They must decide the morality (standards of right and wrong) of
their own actions when they face the many ethical issues that
surround such sensitive areas.
 Specific Ethical Issues
Some of the ethical problems nurses encounter most frequently are:
 Issues in the care of clients with HIV infection & AIDs confidentiality.
Example: Should HIV status be disclosed to the partner (Husband)?
Abortion: A Nurse may refuse to participate but must not judge the patient
Organ or tissue transplantation & donation: Requires consent, may
involve cultural beliefs. Example: Family disagrees despite the patient being
registered as a donor.
End-of-life decisions: Withdrawal of treatment vs euthanasia. Example:
Patient requesting to stop feeding tube.
Cost-containment issues that jeopardize client welfare and access to
healthcare (resource allocation).
Client confidentiality (e.g., computerized information management).
 A Model for Making Ethical Decisions
1. Identify if the issue is moral: Identify dilemma (Assessment)
2. Clarify values (Problem Identification)
3. Identify options: analyze options & weigh consequences.
4. Act & evaluate.
5. Choose the best action (Implementation)
6. Follow ethical principles

• Example: Deciding between respecting DNR vs family demands.

 Ethical Principles
Ethical principles are fundamental guidelines that influence decision-
making and are frequently used by health care workers to assist with
ethical decision-making.
[Link] ‫االستقاللية‬
[Link]‫عمل الخير‬
[Link] ‫عدم االيذاء‬
[Link] ‫العدالة‬
[Link] ‫الوالء وااللتزام‬
[Link] ‫الصدق‬
[Link] ‫سرية‬
[Link] & Responsibility ‫المسائلة والمسؤولية‬
Lecture No.14
1. Autonomy ‫االستقاللية‬
 Respecting patient choices: making one’s own decision
 This presumes that individuals are always capable of making independent
choices for themselves.

 Health care workers know this is not always the case. Children, comatose
individuals, and the seriously mentally ill are examples of clients who are
incapable of making informed choices. In these instances, a representative of
the individual is usually asked to intervene and give consent.

 Health care workers must ensure that respect for an individual’s autonomy is
not disregarded in favor of what another person may view as best for the client.

Example: Patient refusing blood transfusion due to religion. Not giving medication
without consent = autonomy.
Patient’s Bill of Rights
***Derived from the ethical principle of
Autonomy

• This document reflects the

acknowledgment of the patient’s right
to actively participate in his/her health
care and to communicate openly with
the health care team

• [Link]
2. Beneficence‫عمل الخير‬
• Doing good for the patient. refers to one’s duty to benefit or promote the
good of others.
• Defined as “the principle of doing well and providing care to others.”
• Refers to taking positive actions to help others.

• Example 1: Repositioning the patient to prevent bedsores.

• Example 2: A child’s immunization may cause discomfort during

administration, but the benefits of protection from disease for the individual
and society outweigh the temporary discomfort.
3. Nonmaleficence ‫عدم االيذاء‬
 Do no harm.

 Nonmaleficence is the requirement that health care providers do

no harm to their clients, either intentionally or unintentionally

 An example of this conflict might occur when administering

chemotherapy to a cancer patient, knowing it will prolong his or
her life, but create “harm” (side effects) in the short term.

 Example: Checking medication dose carefully to avoid error.

4. Justice ‫العدالة‬
 Fair and equal treatment.
 It lies with the right of individuals to be treated equally
regardless of race, sex, marital status, medical
diagnosis, social standing, economic level, or religious
belief.
 The concept of justice reflects a duty to treat all
individuals equally and fairly.
 When applied to health care, this principle suggests that
all resources within society (including health care
services) ought to be distributed evenly, regardless of
socioeconomic status. However, some people need to
be treated differently if they require special care beyond
what others may need.

 Example: Equal triage assessment for all emergency

patients.
5. Fidelity ‫الوالء وااللتزام‬
 Keeping promises.
 Fidelity is about
 Being Faithful .
 keeping promises .
 always doing what is right
 being trust worthy
 Confidential .
 Showing respect and dignity .
 respecting autonomy .
 Acting in their best interest.

 Example: Returning with pain medication when promised.

6. Veracity ‫الصدق‬
 Being truthful.
 The principle of veracity refers to one’s duty to always be truthful.
 “Veracity requires that the health care provider tell the truth and not
intentionally deceive ‫ غالط‬or mislead ‫ خدع‬clients.”
 There are times when this principle must be limited, such as when the truth
would knowingly cause harm or interfere with the recovery process.
 Being honest is not always easy, but lying is rarely justified.‫مبرر‬
 Clients have the right to know about their diagnosis, treatment, and
prognosis.

Example: Honestly explaining side effects of treatment.

7. Confidentiality ‫سرية‬
It refers to clients’ rights to privacy protection without diminishing access to
quality care.

It is important for a trusting relationship.

Nurses will not share information about the client unless it is agreement from
the client or required by the law.
8. Accountability & Responsibility ‫المسائلة والمسؤولية‬
 You are responsible and accountable for your actions based on:

Your clinical training

Your title
Scope of practice
Standard of care guidelines
Policies and procedures of your health care facility
 CODE OF ETHICS
• A formal statement of the rules of ethical behavior for A
particular group of individuals

• The Nursing Code of Ethics provides values;

standards, and principles to help nursing function as
profession
• The original code was developed in 1985 by the ANA
board of directors and the congress on nursing practice
• [Link]
ndards/CodeofEthicsforNurses/Code-of-Ethics-For-
[Link]

• Nurses are responsible for being familiar with the code

that governs their practice.
 Advocacy
An advocate is one who expresses and defends another’s cause.
The overall goal of the client advocate is to protect clients’ rights.
Advocate informs clients about their rights and provides them with the information they need to
make informed decisions.
Clients have the right to expect a nurse–client relationship based on shared respect, trust,
collaboration in solving health and healthcare-related problems, and consideration of their thoughts
and feelings.

Advocacy Role of the Nurse

• Protect client rights.
• Support informed decisions.
• Ensure access to services.
• Promote dignity and respect.
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