NURSING LEADERSHIP AND MANAGEMENT

1ST SEMESTER SY 2020-2021

MIDTERM Handout

NURSING JURISPRUDENCE

I. ETHICO-MORAL ASPECTS OF NURSING PRACTICE

A. Concepts of Ethics

1.Bioethics
➢ a sub-discipline of ethics that studies medical morality
➢ advances in technology has created questions for healthcare professionals
regarding its use on life and death

2.Value Systems
➢ a set of related values
➢ Values are learned and change with maturity and experience
➢ the number of values and individual holds is not as important as what values
they consider important

3.Beliefs
➢ organized ways of thinking about why people exist within the universe
➢ the purpose of beliefs is to explain concepts such as: life and death, good and
evil, health and illness

4.Ethics and Morals

➢ Ethics deals with the “rightness” or “wrongness” of human behavior and with the
motivation behind the behavior
➢ Morals are an individual’s own code for acceptable behavior arising from an
individual’s conscience

B. Ethical Principles

1.Autonomy (Respect for Human Dignity)

❖ the fundamental principle that underlies all nursing practice is Respect for Human
Dignity (respect for the inherent worth, dignity, human rights of every individual)
❖ the right to decide voluntarily whether to participate in treatment without risking
penalty or prejudice
❖ the right to ask questions/clarifications, refuse to give info, terminate treatment
❖ freedom from coercion of any type (penalty for refusing or excessive rewards for
agreeing to treatment)

A. The Right to Self-Determination

The Patient has the moral and legal right to:

1. voluntarily determine what will be done with their own person
2. be given accurate, complete, & understandable info in a manner that
facilitates an informed judgment
3. be assisted with weighing the benefits, burdens, and available options in their
treatment, including the choice of no treatment
4. to accept, refuse, or terminate treatment without deceit, undue influence,
duress, coercion, or penalty

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5. to be given necessary support throughout the decision-making and treatment

process
6. the opportunity to make decisions with family and SO’s
7. provision of advice and support from knowledgeable nurses and other health
professionals
8. be involved in planning their own health care to the extent they are able and
choose to participate

The Nurse:
1. has an obligation to be knowledgeable about the moral and legal rights of all
patients to self-determination
2. preserves, protects, supports these interests by assessing the
> patient's comprehension of the information
> implications of decisions
3. ensures that in situations in which the patient lacks the capacity to decide, a
designated surrogate decision-maker should be consulted
4. the surrogate is to make decisions as the patient would, based upon the
patient's previously expressed wishes and known values
5. in the absence of a designated surrogate decision-maker, decisions
should be made in the best interests of the patient, considering the patient's
personal values to the extent that they are known
6. supports patient self-determination by
> participating in discussions with surrogates
> providing guidance and referral to other resources as needed
> identifying & addressing problems in the decision-making process
7. respects not just the specific decision but also the patient's method of
decision-making
> people of some cultures place less weight on individualism and
choose to defer family or community values in decision-making

8. recognizes that there are situations in which the right to individual self-
determination may be outweighed or limited by the rights, health and welfare of
others, particularly in relation to public health considerations
> limitation of individual rights must always be considered a serious
deviation from the standard of care
> justified only when there are no less restrictive means
available to preserve the rights of others and the demands of
justice
B. Right to Full Disclosure
❖ right to make informed, voluntary decisions about participation in treatment
❖ the nurse has fully described the > nature of the treatment
> patient’s right to refuse treatment
> nurse’s responsibilities
> likely risks and benefits
❖ patients who are fully informed about the nature of the treatment, its risks and
benefits, are in a position to make rational decisions about participating in the
treatment
❖ normally provided to patients before the treatment begins
❖ basis of Informed Consent
▪ Informed Consent means that patients
> have adequate information regarding the treatment

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> can comprehend the information

> have the freedom of choice enabling consent or decline voluntarily
* may not be taken if data will be collected
anonymously

▪ Informed Consent requires Documentation

> patients sign a consent form
> signed by both parties (patient and provider of treatment)
> copies to be retained by both parties

C. Vulnerable Subjects
❖ those incapable of giving fully informed consent or at high risk because of their
circumstances
1. Children
> obtain informed consent of parents or guardians
> if child is at least 7 y/o, obtain child’s assent (child’s affirmative agreement
to participate)
> if child is 13 y/o and is developmentally mature to understand the basic
information involved in
informed consent, obtain the written consent of the child

2. Mentally or emotionally disabled people (MR, senility, MI, unconsciousness)

> unable to weigh risks and benefits
> obtain written consent of legal guardian (may not have the person’s best
interest in mind)
> obtain informed consent from someone whose primary interest is the
person’s welfare
> nurse must take effort in obtaining person’s assent

3. Severely ill or physically disabled people

> assess ability to make reasoned decisions about study participation
> utilize special procedures in obtaining consent (written if deaf,
audio/videotaping for those who cannot read or write)

4. Terminally ill
> carefully assess benefit-risk ration, participants do not benefit from the
research
> ensure health and comfort are not compromised

5. Institutionalized people
> often depend on health care personnel
> may feel pressured and think that treatment will be jeopardized by failure
to cooperate
> inmates of prisons may feel constrained to give free consent as they have
lost autonomy
> Nurse must emphasize voluntary nature of participation

6. Pregnant women
> safeguard both the pregnant woman and the fetus
> heightened physical/psychological risks, fetus cannot give informed
consent

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> treatment must meet the health needs of the pregnant woman with a
minimal risk to the fetus

2. Nonmaleficence (“Above all, do no harm”)

- requires that no harm be caused to an individual, either unintentionally or
deliberately
- requires nurses to protect individuals who are unable to protect themselves

A. Freedom from Harm (physical, psychological, economic)

• minimize all types of harm
• unacceptable to expose participants to experiences that result in
serious/permanent harm
• terminate treatment if continuation results to death, injury, disability, undue
distress
• carefully phrasing questions to avoid psychological harm
• Risk Reduction
Ex: Effects of timing (1hr vs. 2 hrs) of initial bath on newborn
temperature
Exclude infants with abnormal conditions
Debriefing Sessions to permit queries, airing of complaints
Referrals to appropriate health, social, psychological services

B. Freedom from Exploitation

• patients should not be placed at a disadvantage or expose them to situations for
which they have not been prepared
• inform patients that any information they will provide will not be used against
them in any way
Ex: Drug user must not fear criminal authority report
AIDS patient must not lose medical benefits
• nurse-patient relationship must not be exploited
• Overt Exploitation (sexual, blood samples being used commercially)
• Subtle Exploitation (not abiding by agreed-upon time limits)

3. Beneficence
- “doing good” and promoting the welfare of others
- deeds of charity, mercy, and kindness toward the individual.
- nurses need to assist patients in meeting ALL their needs

a. Risk-Benefit Ratio / Benefit-and-Harm Relationship

• assess risks and benefits that would be incurred during treatment and share these with
patients so they can evaluate whether it is in their best interest to participate

General Guideline:
• the degree of risk to be taken should never exceed the potential benefits to be gained
• Minimal Risk: risks anticipated to be no greater than those ordinarily encountered in
daily life

b. The Sanctity of Life

• Sanctity of human life is defined as “the obligation not to take human life” (Fry &
Veatch,2000).

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• ethical decisions when it comes to withholding or withdrawing life-sustaining treatments

or assisting suicide
• active euthanasia and withholding nutrition and hydration for the patient should be
made by the client or surrogate with the health-care team (ANA, 2001).
Ex.: Considering the benefit-and-harm relationship of withholding
nutrition, recognizing that, sometimes, living causes more harm to
the individual than dying.
Differentiating artificial nutrition and the individual being able to
consume food and water by mouth, ANA states that only artificial
nutrition may or may not be justified.

4. Justice (The Right to Fair Treatment)

• the right to fair and equitable treatment
• respect for cultural and other forms of human diversity
• the right to courteous and tactful treatment at all times
• nondiscriminatory and nonprejudicial treatment of patients who decline or withdraw
after agreeing to participate in a treatment regimen
• honoring all agreements (adherence to procedures described)
• nurse is accessible to patient at any point in the treatment for clarification of
information
• patient with access to professional assistance for any physical or psychological damage
• debriefing, if necessary, to divulge information withheld before the treatment and to
clarify issues

5. Fidelity
• loyalty, the promise to fulfill all commitments and obligations
• nurse managers are bound by their commitments to their employees
• the basis of accountability

6. Confidentiality
• anything stated to nurses or health-care providers by clients must remain confidential
• the only times this principle may be violated are:
> if clients may indicate harm to themselves or others
> if the client gives permission for the information to be shared

a. Right to Privacy
▪ the nurse safeguards the patient's right to privacy
▪ the need for health care does not justify unwanted intrusion into the
patient's life
▪ the nurse advocates for an environment that provides for sufficient
physical privacy, including auditory privacy for discussions of a personal
nature and policies and practices that protect the confidentiality of
information.

b. Confidentiality
▪ patients have the right to expect that any data provided will be kept in
strictest confidence
▪ the nurse has a duty to maintain confidentiality of all patient information
(oral, written or electronic)

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▪ patient's well-being could be jeopardized and the fundamental trust

between patient and nurse destroyed by unnecessary access to data or by
the inappropriate disclosure of identifiable patient information
▪ nurses must strive to achieve Anonymity of patients whenever possible
> occurs when patients are not linked with the data they have
provided
> a pledge that the information patients provide will not be
publicly reported in any manner that identifies them and will
not be accessible to others (strangers or otherwise)
▪ achieving Anonymity:
> relevant data be shared with those members of the health
care team who have a need-to-know.
> only information pertinent to a patient's treatment and
welfare is disclosed only to those directly involved with
the patient's care
> when using electronic communications, special effort should
be made to maintain data security
▪ Duties of confidentiality, however, are not absolute and may need to be
modified to protect the patient, other innocent parties and in
circumstances of mandatory disclosure for public health reasons

7. Veracity (The Right to The Truth)

• truth telling by ALL concerned in patient care
• Veracity is an important component of building trusting relationships
• the nurse is obliged to tell the truth when a patient asks about his condition,
without false reassurances and a skilled use of therapeutic communication

8. Accountability
• Acceptance of accountability and responsibility
> individual registered nurses bear primary responsibility for the nursing care that
their patients receive and are individually accountable for their own practice
> nursing practice includes direct care activities, acts of delegation, and other
responsibilities such as teaching, research, and administration
• the nurse determines the appropriate delegation of tasks consistent with the nurse's
obligation to provide optimum patient care

C. Nursing Code of Ethics

❖ There are numerous approaches for addressing ethics: adopting or subscribing to
ethical theories (humanist, feminist, social ethics), adhering to ethical principles and
cultivating virtues. The Code of Ethics for Nurses reflects all these approaches.

D. Model of Ethical Nursing Care

1. Ethical Dilemmas
- occur when a problem exists between ethical principles
- deciding in favor of one principle usually violates another
- both sides have “goodness” and “badness” associated with them

2. Recognizing Ethical Dilemmas

- Nurses may fail to recognize an ethical dilemma due to:

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a. Paternalism
➢ occurs when nurses think that they know what is best for their clients,
often imposing their own methods for care and treatment decisions
➢ may occur in the psychiatric clinical setting where clients exhibit clinical
symptoms of confusion, depression, anxiety or when clients are unable to
communicate their needs due to communication disorders or MR
b. Lack of training in ethics
c. Lack of available resources to describe ethical issues

*Failure to act or intervene when an ethical dilemma is identified

violates the Code of Ethics for Nurses and the Nursing Practice Act
3. MORAL Model Ethical Decision Making (Thiroux, 1977; Halloran, 1982; Challly & Loriz
1998)

M Mule over the dilemma.

Identify the major players and define the issues in the dilemma.
Whose problem is it?
Who should make the decision?
Who is affected by the decision?
What ethical principles are related to the problem?
Are there legal issues related to the dilemma?

O Outline the options.

Identify and examine all options (including less realistic and conflicting)
Which acceptable solutions are available?
What options does the client propose?

R Resolve the dilemma.

Review the issues and options, applying basic principles of ethics to each
option.
Decide the best option.
Which option is the most acceptable and therapeutic?
Discuss this decision with the client, considering risks and benefits.

A Act by applying the chosen option.

Carry out the decision.
This step is usually the most difficult because it requires actual
implementation
(previous steps require only dialogue and discussion).
Collaboration with others may be necessary.

L Look back and evaluate the entire process.

No process is complete without a thorough evaluation.
Evaluate the impact of the decision regarding what went right or what
went wrong.
Ensure that those involved can follow through on the final option.

If not, a second decision may be required, and the process must start
again at the initial step.
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Philippine Patient’s Bill of Rights

The following rights of the patient shall be respected by all those involved in his care:

1 Right to Appropriate Medical Care and Humane Treatment.

❖ Every person has a right to health and medical care corresponding to his state of
health, without any discrimination and within the limits of the resources, manpower and
competence available for health and medical care at the relevant time.

❖ The patient has the right to appropriate health and medical care of good quality.

❖ During such care, his human dignity, convictions, integrity, individual needs, and culture
shall be respected.

❖ If any person cannot immediately be given treatment that is medically necessary he

shall, depending on his state of health, either be directed to wait for care, or be
referred or sent for treatment elsewhere, where the appropriate care can be provided.
If the patient must wait for care, he shall be informed of the reason for the delay.

❖ Patients in emergency shall be extended immediate medical care and treatment without
any deposit, pledge, mortgage, or any form of advance payment for treatment.

2 Right to Informed Consent.

❖ The patient has a right to a clear, truthful and substantial explanation, in a manner and
language understandable to the patient, of all proposed procedures, whether
diagnostic, preventive, curative, rehabilitative or therapeutic, wherein the person who
will perform the said procedure shall provide his name and credentials to the patient,
possibilities of any risk of mortality or serious side effects, problems related to
recuperation, and probability of success and reasonable risks involved.

✓ Provided that, the patient will not be subjected to any procedure without
his written informed consent, except in the following cases:
a. in emergency cases, when the patient is at imminent risk of
physical injury, decline or death if treatment is withheld or
postponed. In such cases, the physician can perform any
diagnostic or treatment procedure as good practice of medicine
dictates without such consent.
b. when the health of the population is dependent on the adoption
of a mass health program to control epidemic.
c. when the law makes it compulsory for everyone to submit to a
procedure.
d. when the patient is either a minor, or legally incompetent, in
which case, a third-party consent is required.
e. when disclosure of material information to patient will
jeopardize the success of treatment, in which case, third party
disclosure and consent shall be in order.
f. when the patient waives his right in writing.

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❖ Informed consent shall be obtained from a patient concerned if he is of legal age and of sound
mind. In case the patient is incapable of giving consent and a third-party consent is required,
the following persons, in the order of priority stated hereunder, may give consent:
✓ Spouse
✓ son or daughter of legal age
✓ either parent
✓ brother or sister of legal age
✓ guardian

❖ If a patient is a minor, consent shall be obtained from his parents or legal guardian.

❖ If next of kin, parents or legal guardians refuse to give consent to a medical or surgical
procedure necessary to save the life or limb of a minor or a patient incapable of giving
consent, courts, upon the petition of the physician or any person interested in the welfare of
the patient, in a summary proceeding, may issue an order giving consent.

3 Right to Privacy and Confidentiality.

❖ The privacy of the patients must be assured at all stages of his treatment. The patient
has the right to be free from unwarranted public exposure, except in the following
cases:
✓ when his mental or physical condition is in controversy and the
appropriate court, in its discretion, orders him to submit to a physical or
mental examination by a physician.
✓ when the public health and safety so demand.
✓ when the patient waives this right.

❖ The patient has the right to demand that all information, communication, and records
pertaining to his care be treated as confidential.
❖ Any health care provider or practitioner involved in the treatment of a patient and all
those who have legitimate access to the patient's record is not authorized to divulge
any information to a third party who has no concern with the care and welfare of the
patient without his consent, except:
✓ when such disclosure will benefit public health and safety.
✓ when it is in the interest of justice and upon the order of a competent
court.
✓ when the patients waive in writing the confidential nature of such
information;
✓ when it is needed for continued medical treatment or advancement of
medical science subject to de-identification of patient and shared medical
confidentiality for those who have access to the information.

❖ Informing the spouse or the family to the first degree of the patient’s medical condition
may be allowed; provided the patient of legal age shall have the right to choose on
whom to inform.

❖ In case the patient is not of legal age or is mentally incapacitated, such information
shall be given to the parents, legal guardian or his next of kin.

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4 Right to Information.
❖ In the course of his/her treatment and hospital care, the patient or his/her legal
guardian has a right to be informed of the result of the evaluation of the nature and
extent of his/her disease, any other additional or further contemplated medical
treatment on surgical procedure or procedures, including any other additional medicines
to be administered and their generic counterpart including the possible complications
and other pertinent facts, statistics or studies, regarding his/her illness, any change in
the plan of care before the change is made, the person’s participation in the plan of
care and necessary changes before its implementation, the extent to which payment
maybe expected from Philhealth or any payor and any charges for which the patient
may be liable, the disciplines of health care practitioners who will furnish the care and
the frequency of services that are proposed to be furnished.

❖ The patient or his legal guardian has the right to examine and be given an itemized bill
of the hospital and medical services rendered in the facility or by his/her physician and
other health care providers, regardless of the manner and source of payment. He is
entitled to a thorough explanation of such bill.

❖ The patient or his/her legal guardian has the right to be informed by the physician or
his/her delegate of his/her continuing health care requirements following discharge,
including instructions about home medications, diet, physical activity and all other
pertinent information to promote health and well-being.

❖ At the end of his/her confinement, the patient is entitled to a brief, written summary of
the course of his/her illness which shall include at least the history, physical
examination, diagnosis, medications, surgical procedure, ancillary and laboratory
procedures, and the plan of further treatment, and which shall be provided by the
attending physician. He/she is likewise entitled to the explanation of, and to view, the
contents of the medical record of his/her confinement but with the presence of his/her
attending physician or in the absence of the attending physician, the hospital’s
representative.

❖ Notwithstanding that he/she may not be able to settle his accounts by reason of
financial incapacity, he/she is entitled to reproduction, at his/her expense, the pertinent
part or parts of the medical record the purpose or purposes of which he shall indicate in
his/her written request for reproduction.

❖ The patient shall likewise be entitled to medical certificate, free of charge, with respect
to his/her previous confinement.

❖ The patient has likewise the right not to be informed, at his/her explicit request.

5 The Right to Choose Health Care Provider and Facility.

❖ The patient is free to choose the health care provider to serve him as well as the facility
except when he is under the care of a service facility or when public health and safety
so demands or when the patient expressly or impliedly waives this right.

❖ The patient has the right to discuss his condition with a consultant specialist, at the
patient’s request and expense. He also has the right to seek for a second opinion and
subsequent opinions, if appropriate, from another health care provider/practitioner.

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6 Right to Self-Determination.
❖ The patient has the right to avail himself/herself of any recommended diagnostic and
treatment procedures. Any person of legal age and of sound mind may make an
advance written directive for physicians to administer terminal care when he/she suffers
from the terminal phase of a terminal illness: provided that:
✓ he is informed of the medical consequences of his choice.
✓ he releases those involved in his care from any obligation relative to the
consequences of his decision.
✓ his decision will not prejudice public health and safety.

7 Right to Religious Belief.

❖ The patient has the right to refuse medical treatment or procedures which may be
contrary to his religious beliefs, subject to the limitations described in the preceding
subsection: Provided, hat such a right shall not be imposed by parents upon their
children who have not reached the legal age in a life threatening situation as
determined by the attending physician or the medical director of the facility.

8 Right to Medical Records.

❖ The patient is entitled to a summary of his medical history and condition, He has the
right to view the contents of his medical records, except psychiatric notes and other
incriminatory information obtained about third parties, with the attending physician
explaining contents thereof. At his expense and upon discharge of the patient, he may
obtain from the health care institution a reproduction of the same record whether he
has fully settled his financial obligation with the physician or institution concerned.

❖ The health care institution shall safeguard the confidentiality of the medical records and
to likewise ensure the integrity and authenticity of the medical records and shall
keep the same within a reasonable time as may be determined by the Department of
Health.

❖ The health care institution shall issue a medical certificate to the patient upon request.
Any other document that the patient may require for insurance claims shall also be
made available to him within a reasonable period.

9 Right to Leave.
❖ The patient has the right to leave a hospital or any other health care institution
regardless of his physical condition: Provided, that
✓ he/she is informed of the medical consequences of his/her decision.
✓ he/she releases those involved in his/her care from any obligation relative
to the consequences of his decision.
✓ his/her decision will not prejudice public health and safety.

❖ No patient shall be detained against his/her will in any health care institution on the
sole basis of his failure to fully settle is financial obligations.

❖ However, he/she shall only be allowed to leave the hospital provided appropriate
arrangements have been made to settle the unpaid bills: Provided, farther, that unpaid
bills of patients shall be considered as lost income by the hospital and health care
provider/practitioner and shall be deducted from gross income as income loss for that
particular year.

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10 Right to Refuse Participation in Medical Research.

❖ The patient has the right to be advised if the health care provider plans to involve him
in medical research, including but not limited to human experimentation which may be
performed only with the written informed consent of the patient.

❖ Provided, further, that, an institutional review board or ethical review board in

accordance with the guidelines set in the Declaration of Helsinki be established for
research involving human experimentation:

❖ Provided, finally, That the Department of Health shall safeguard the continuing training
and education of future health care provider/practitioner to ensure the development of
the health care delivery in the country.

11 Right to Correspondence and to Receive Visitors

❖ The patient has the right to communicate with relatives and other persons and to
receive visitors subject to reasonable limits prescribed by the rules and regulations of
the health care institution.

12 Right to Express Grievances.

❖ The patient has the right to express complaints and grievances about the care and
services received without fear of discrimination or reprisal and to know about the
disposition of such complaints.

❖ The Secretary of Health, in consultation with health care providers, consumer groups
and other concerned agencies shall establish a grievance system wherein patients may
seek redress of their grievances. Such a system shall afford all parties concerned with
the opportunity to settle amicably all grievances.

13 Right to be Informed of His Rights and Obligations as a Patient.

❖ Every person has the right to be informed of his rights and obligations as a patient.

❖ The Department of Health, in coordination with health care providers, professional and
civic groups, the media, health insurance corporations, people’s organizations, local
government organizations, shall launch and sustain a nationwide information and
education campaign to make known to people their rights as patients, as declared
in this Act. Such rights &d obligations of patients shall be posted in a bulletin board
conspicuously placed in a health care institution.

❖ It shall be the duty of health care institutions to inform patients of their rights as well as
the institution's rules and regulations that apply to the conduct of the patient while in
the care of such institution

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