LEGAL ISSUES IN NURSING

3.  As a nurse it has become an important
necessity to be aware of the legal aspects
associated with caring and helping people
in the health industry today . The first
nursing law created was that of nursing
registration in 1903 and they have only
evolved and expanded over the years to
create a thick book which must be studied
today by aspiring nurses.

4.  It is a standard or rules of conduct
established and in forced by the
government. These are intended to
protect the public.

5. PATIENT CARE
ISSUES
MANAGEMENT
ISSUES
EMPLOYMENT ISSUES
MEDICOLEGAL
ISSUES

7. Nursing
Shortage
Low
salaries
Standard
Care
Health-
Care
Reform

9. Workload
Turnover
malpractice
in nursing
management
Funding

10. Ethics
Collaboration
issues
Effect

12.  Issues related to Nursing Shortage
 Issues in Nurse Migration
 The Right to Work and the Right to Practice
 Exploitation and Discrimination
 Essential Terms and Conditions in an
Employment contract
 Unsatisfactory work performance and
termination of employment

13.  Misconduct and imposition of punishment
 Sexual harassment at the workplace
 Renewal of nursing registration
 Diploma v/s degree in nursing for
registration to practice nursing
 Specialization in clinical area
 Nursing care standards

15.  Issues Specific to Nursing
 Legal Issues in specialty and practice area
 Legal, Ethical, Professional Issues in
Nursing.

16.  Duty to seek Medical Care for the patient
It is the legal duty of the nurse to ensure
that every patient receives safe and
competent care. The nurse cannot
guarantee the patient will receive medical
care that the nurse be a strong advocate for
the patient and use every resource to
ensure medical care is received.

17.  Confidentiality
The law requires the nurse to treat all
such information with strict confidentiality.
This is also an ethical issue. Unless a patient
has told you something that indicates danger
to self or others, you are bound by legal and
ethical principles to keep that information
confidential.

18.  Permission to treat
When people are admitted to hospitals, nursing
homes, and home health services, they sign a
document that gives the personnel in the
organization permission to treat them. Every time
the nurse provides nursing care to person,
however, permission must be obtained. The courts
have ruled that people are expected to have some
understanding of basic care, which means the
nurse should explain briefly what he or she is
about to do.

19.  Informed consent
The principle of informed consent states that
the person receiving the treatment fully
understands the possible outcomes, alternatives to
treatment, and all possible consequences. The
physician is responsible for obtaining informed
consent for medical procedures, such as surgery,
whereas the nurse is responsible for obtaining
informed consent for nursing procedures. Each
institution has forms for informed consent for
complex or serious procedures, such as surgery,
chemotherapy, or electroshock therapy.

20.  Negligence
The law requires nurses to provide safe and
competent care. The measure of safe and
competent care is the standards of care. A standard
of care is the level of care that would be given by a
comparable nurse in a similar situation. Negligence
occurs when a person fails to perform according to
the standards of care or as a reasonably prudent
person would perform in the same situation. It is
the responsibility of the nurse to monitor the
patient.

21.  Malpractice
Malpractice is a term used for
negligence. Malpractice specifically refers to
negligence by a professional person with a
license.

22.  Fraud
Few cases of fraud exist in nursing, but it
does need to be mentioned. Fraud is a
deliberate deception for the purpose of
personal gain and usually is prosecuted as a
crime. Most courts are harder on cases of
fraud compared with cases of negligence or
malpractice because fraud is deliberate and
results in personal gain.

23.  Assault and Battery
Assault is the threat of unlawful touching of
another, the willful attempt to harm someone.
Battery is the unlawful touching of another without
consent, justification, or exercise. In legal medicine
battery occurs if a medical or surgical procedure is
performed without patient consent. In both
situations, it is not necessary for harm to occur.
The events simply need to happen.

24.  False Imprisonment
Preventing movement or making a
person stay in a place without obtaining
consent is false imprisonment. This can be
done through physical or non physical
means. Physical means include using
restraints or locking a person in a room. In
some unique situations, restraints and
locking patients in a room are acceptable
behaviours.

25.  In these situations, be sure the nurse to know the
standards of care and the institution‘s policies regarding
physical restraints. To restrain a person is a serious
decision. It requires a physician‘s order and permission
of the patient or the patient‘s family members. The best
approach to avoiding a charge of false imprisonment is
to work closely with patients who seem at risk for
confinement. Talk to them, do an ongoing assessment,
assign extra staff to assist the person, or implement
some other creative way to manage the problem.

26.  Invasion of privacy
Clients have claims for invasion of privacy‘,
e.g. their private affairs, with which the public
has no concern, have been publicized. Clients are
entitled to confidential health care. All aspects of
care should be free from unwanted publicity or
exposure to public scrutiny. The precaution
should be taken sometimes an individual right to
privacy may conflict with public‘s right to
information for e.g. in case of poison case.

27.  Nurse Practice Act
Each state has what is called a Nurse Practice
Act. The guidelines and laws outlined in the act
pertain to all nurses who are licensed in that
particular state. Nurse limitation is one of those
laws. Each nurse has a limitation on what he is
allowed and trained to do. He must follow the chain
of command, especially with the care of a patient

28. If he does not have the authority or
knowledge to give a prescription, analyze a
lab report, or advise the patient on treatment,
he may not legally do so. Any wrong
information or practice he commits is
punishable by the law and the patient or
family may file a suit against him and the
health agency or hospital he works for.

29.  Patient's Advocate
A nurse has a legal obligation to act as the
patient's advocate in case of emergency. The nurse is
to act as the liaison between the patient and the
health care provider, such as a physician. The nurse
will monitor the patient, ensuring that if any
complications or abnormalities arise, a physician
notified immediately. The nurse is legally obligated to
keep the personal data and information of the patient
private; not doing so is a violation of the code of
ethics for nurses.

30.  Administering Medication
Nurses are responsible for administering the
correct doses and medications to patients. If the
nurse gives a fatal dosage amount, she may face
legal malpractice suits. It is also the
responsibility to research the patient's records,
or ask the patient and family members if there
are any allergies or complications that may pose
a risk if a certain medication is administered.

31.  Report It or Tort It
Allegations of abuse are serious matters. It is
the duty of the nurse to report to the proper
authority when any allegations are made in
regards to abuse (emotional, sexual, physical,
and mental) towards a vulnerable population
(children, elderly, or domestic). If no report is
made, the nurse is liable for negligence or wrong
doing towards the victimized patient.

32.  Rights to Privacy
The nurse is responsible for keeping all
patient records and personal information private
and only accessible to the immediate care
providers, according to the Health Insurance
Portability and Accountability Act of 1996
(HIPAA). If records get out or a patient's privacy is
breached, the liability usually lies on the nurse
because the nurse has immediate access to the
chart.

33.  Document, Document, Document
It is the nurse's responsibility to make sure everything
that is done in regards to a patient's care (vital signs,
specimen collections, noting what the patient is seen
doing in the room, medication administration, etc.), is
documented in the chart. If it is not documented with the
proper time and what was done, the nurse can be held
liable for negative outcomes.
A note of caution: if there was an error made on the chart,
cross it out with one line (so it is still legible) and note the
correction and the cause of the error.

34.  Maternal and infant Nursing
Many legal issues are involved in the care of
mother and her infant. Generally the causes of
lawsuits for malpractice in this area may be divided
into two categories who handling the mother and
child. Lawsuits brought against physicians/
doctors and nurses differ, reflecting the well-
recognized differences between these professions
and their responsibilities.

35. A likely against a doctor who is in charge of looking after
mother and infant might be one of the following:-
 Failure to diagnose a high risk pregnancy.
 Delay in performing a caesarean section.
 Improper vaginal delivery or failure to perform a
caesarean section.
 Improper use of forceps.
 Incidence surrounding including labour and the use of
oxytocin.
 Delay in arriving at the hospital.
 Non attendance at the delivery.

36.  Problems of medication
 Failure in adequate client monitoring.
 Failure to adequately assess the client.
 Failure to report changes in the patient

37.  Abortions
 Nursing care of new born.
 Informed Consent
 Prenatal Screening
 In vitro fertilization (IVF)
 Surrogacy
 Fetal tissue research
 Preterm and high risk neonate treatment


38.  Paediatric nurses are responsible for
preventing children, in their care, from
accidentally harming themselves.
 All poisonous substances and sharp objects
should be kept out of the reach of children.

39.  It is advisable that the health care
professional including nurses should report
to the concerned authority if they come
across the suspected cases may be liable
for civil or criminal legal action.

40. Nurses are responsible for performing
all procedures correctly and exercising
professional judgement. A nurse who does
not meet the accepted standards of practice
or who perform duties in a careless fashion
runs a risk of being found negligence.

41.  Over looked sponges, instruments needles
 Burns
 Falls
 Injury due to the use of defective apparatus or
supplies
 Injury due to administration of wrong medicine,
wrong dosage and wrong concentration.
 Assault and battery
 Failure to report accidents
 Maintenance of records and reports

42. The practice of psychiatric nursing is influenced
by the law, particularly in concern for the rights of
patients and the quality of care they are receiving.
A psychiatric nurse should be sufficiently
acquainted with the legal aspects of psychiatry so
that she/he can be aware of the patient‘s rights
and can avoid giving poor advice or innocently
involving herself/himself in a legal entanglement.

43.  Informal Admission
This type of admission to the psychiatric
hospital occurs in the same way as a person is
admitted to a general medical hospital, i.e.
without formal or written application. The
individual is then free to leave at any time, as
he would be in a general medical hospital.
 Restraints
 Discharge

44.  In olden days nurses were working under the control
and supervision of doctors. But in modern practice
nurses are able to assess, diagnose, plan, implement
and evaluate nursing care independently. As we begin
professional practice, it is essential to understand the
law that defines the nurse‘s responsibility and duties.
Especially the community health nurse must be very
careful while doing services in the community. Because
there is team of people working in the hospital.

45.  Whereas in the community the community
health nurses are alone and most of the
time she is in a position to implement the
services at home. So, she must be more
careful and she should have enough
knowledge on legal issues.

46.  Informed consent: Granted freedom, written or oral form
(procedures, expected outcome, complication, side effects,
and alternative treatment.
 Contracts: Exchange of promises between two parties. The
agreement may be written or oral. (E.g. patient and his
family and health care team.)
 Collective bargaining: Policies, legal procedures, up to date
knowledge.
 Competent practice: It is most important and best legal
safeguard.

47.  Intentional Torts
Assault: It is a threat or an attempt to
make bodily contact with another person
without that person‘s consent.
Battery: It is an assault that is carried out
with willful angry and violent or negligent
touching of another person‘s body or
clothes.

48.  Defamation: It is an intentional tort makes derogatory
remarks about another.
 Slander: oral defamation of character.
Libel: Written defamation (petition)
 Invasion of Privacy
 All information should be confidential.
 Interacting with the family members.
 Avoid unnecessary exposure.
 Checking of all machines.
 Carryout research activities.
 Using tape recorder, video or photos.

49.  False Imprisonment: A person cannot be
legally forced to remain in health centers or
hospital. (Unjustified intension)
 Fraud: Willful and purposeful interpretation
or misinterpreting the outcome of
procedure or a treatment. (License may be
prosecuted under the NP Act.

50.  Negligence: An act of negligence may be
enacting of omission or commission.
 Malpractice or Negligence
 Liability: It involves four elements that must
be established to prove that malpractice or
negligence has occurred.

51.  Duty: Execution of safety measures.
 Breach of Duty: Failure to note and report
to the higher authority about the
seriousness.
 Causation: Failure to use appropriate safety
measures.
 Damages: Lengthened hospital stay and
need for rehabilitation (Injection abscess)

52.  These three main duties are generally considered to
be to respect a patient's confidentiality and autonomy
and to recognize the duty of care that is owed to all
patients. These three main duties are professional
duties, however there are legal implications if they are
breached, therefore they are also legal duties; ethical
considerations arise in contemplation of these duties,
such as consideration of when they can be breached
and they are therefore ethical duties as well.

53.  The medical and nursing professions are bound
by their own code of ethics which is enforced by
disciplinary procedures. The professional
governing body has for the most part a more
immediate influence over the conduct of its
members than does the law, which is invoked
relatively rarely in medical matters.

54.  As a means of pre-empting the necessity for
disciplinary proceedings, the NMC issues
guidance on aspects of a practitioner's duties
and responsibilities in areas such as consent,
confidentiality and medical research, to
prevent poor practice at source.

55.  Confidentiality is central to trust between doctors and
patients. Without assurances about confidentiality,
patients may be reluctant to give doctors the
information they need in order to provide good care.
In addition to the civil requirement to maintain
confidentiality there is a professional requirement for
to maintain the patient's confidentiality and failure to
do so is a breach of good medical practice and will
attract sanctions.

56.  The right to determine what happens to ones
own body is the right to autonomy. The
words autonomy and autonomous are used in
respect of a capacity, a condition and a right.
Successful relationships between doctors and
patients depend on trust.

57.  To establish that trust must respect patients'
autonomy - their right to decide whether or
not to undergo any medical intervention even
where a refusal may result in harm to
themselves or in their own death. Patients
must be given sufficient information, in a way
that they can understand, to enable them to
exercise their right to make informed
decisions about their care.

58.  Professional negligence. E.g. ignoring the
seriousness.
 Practicing medical without license in the
community.
 Obtaining nursing license by fraud or allowing
others to use your license.
 Participating in criminal abortion. E.g. Quacks.

59.  Not reporting substandard medicine or
nursing care.
 Providing patient care while under the
influence of alcohol or drugs.
 Giving narcotics without an order.
 Falsely holding oneself as family
practitioner of nurse practitioners.

61. Accreditation Education programme is
evaluated and recognized by
National Accreditation
Board.
Licensure The state determines certain
minimum requirement to
practice as nurse. (e.g.
Negligence, malpractice,
wrong treatment and
alcoholism)

62. Certification Entry level competence.
Specific knowledge and
experience in specified
areas needed.
Standards Guidelines issued by
councils, Qualifications,
Standards, rules.
Nurse Practice Act Violation of rule care
result in disciplinary action

63.  Physician's Order:
Physician is responsible for directing
medical treatment. Nurses are obligated to
follow physician‘s oders unless they believe
that the orders are not accurate or would
be detrimental to the clients.

64.  A nurse carrying out an inaccurate order
may be legally responsible for any harm
suffered by the client. Verbal orders are
not recommended because they have
possibilities for error. If a verbal order is
necessary, during an emergency, it should
be written and signed by the physician as
soon as possible, usually within 24 hours.

65.  Short- staffing:
The issue of inadequate staff may arise
sometimes. Legal problems may arise if there
is not enough nurse to provide competent
care. If assigned to take care of more clients
than is reasonable, nurse should attempt to
reject assignments by informing the nursing
supervisor that they are inappropriate.

66. Nurses should not walk out when staff is
inadequate because charges of abandonment
can be made.ack of experience in taking care
of the type of clients in the new nursing unit.
They should also request for an orientation
about the unit.

67.  Informed consent: Granted freedom, written or oral
form (procedures, expected outcome, complication,
side effects, and alternative treatment.
 Contracts: Exchange of promises between two
parties. The agreement may be written or oral. (E.g.
patient and his family and health care team.)
 Collective bargaining: Policies, legal procedures, up
to date knowledge.
 Competent practice: It is most important and best
legal safeguard

69.  Documentation of all unusual incidences.
 Report all unusual incidences.
 Know your job description.
 Follow policies and procedures as
established by your employing agency.
 Keep your registration updated.

70.  Perform procedures that you have been taught and
that are within the standard scope of your practice.
 Protect patients from injuring themselves.
 Remain alert and focused.
 Establish and maintain rapport with patients and
family.
 Seek and clarify orders when the patient‘s medical
condition changes.
 Practise safety with physician‘s verbal orders.

71.  Remove side rails from patient‘s bed unless
there is an order or hospital policy to do so.
 Allow patients to leave the hospital or
nursing home unless there is an order or a
signed release.
 Accept money or gifts from patients.
 Give advice that is contrary to physician
orders or the nursing care plan.

72.  Give medical advice to friends and
neighbours.
 Attempt to practice medicine.
 Witness a patient‘s will.
 Take medications that belong to patients.
 Worked as a licensed practical/vocational
nurse in a state in which you are not
licensed.

74.  Serve as a role model by providing nursing care
that meets or exceeds accepted standards of care.
 Is current in the field and seeks professional
certification to increase expertise in a specific field.
 Reports substandard nursing care appropriate
authorities.
 Fosters nurse/ patients relationships that are
respectful, caring and honest, thus reducing the
possibility of future lawsuits.

75.  Joins and actively supports professional
organizations to strengthen the lobbying efforts of
nursing in health care legislation.
 Practices nursing within the area of the individual
competence.
 Prioritizes patient‘s rights and welfare first in
decision- making.
 Demonstrates vision, risk taking, and energy in
determining appropriate legal boundaries for
nursing practices thus defining what nursing is and
should be in the future.

76.  Delegates to subordinates wisely, looking
at the managers scope of practice and that
of those they supervise.
 Understands and adheres to institutional
policies and procedures.
 Practices nursing with scope of state
nursing within the scope of the state nurse
practice act.

77.  Monitors subordinates to ensure that they have
a valid, current and appropriate license to
practice nursing.
 Uses foresee ability of harm in delegation and
staffing decisions.
 Increases staff awareness of intentional torts
and assists them in developing strategies to
reduce their liability in these areas.

78. Issues need deliberations and common consensus. They
need to be reviewed periodically. Issues which seem not
feasible, and ideal, may become practice with the
change of time. Some of these issues threaten nurses
who do not keep up with the changing development.
These issues are base for the future trends in care.
Hence, it is important for nursing personnel working in
hospital, community and educational field to develop
understanding of Legal and Ethical issues of Nursing.

80.  Abstract
 Background:
 Nurses are highly vulnerable to facing ethical and legal
issues as they deal with human life and death. In Nepal,
the accusation of malpractice and negligence is rising
every day in health sector [1].Various studies have
shown that knowledge of nurses in ethical and legal
aspects is unsatisfying which is further increasing
ethical dilemmas and legal issues in health sector

81.  Objectives: To assess the knowledge level of
nurses on legal and ethical aspects of nursing
and find out the association between
knowledge and selected variables (Age, Years
of experience, Educational Level, In-service
education, Area of Work) in selected hospitals
of Lalitpur district.

82.  Methodology: Descriptive, cross-sectional
design was adopted to find out knowledge
among 168 nurses in Sumeru, Sumeru City &
Ganeshman Singh Memorial Hospital of
Lalitpur district. Non -probability purposive
sampling technique was used. The semi-
structured questionnaire was self-
administered to collect the data. Data were
analyzed using SPSS software, descriptive
analysis, and chisquare test.

83.  Findings: Overall, 59.5% of the respondents
had adequate and 40.5% had inadequate
knowledge of ethical and legal aspects. There
was no significant association between the
knowledge score and the selected variables.
 Conclusions: Around 40% of the respondents
had inadequate knowledge of ethical and legal
aspects of nursing. The present knowledge
level of nurses emphasizes the need for
making aware of these topics

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