SEMINARS ON ADVANCED NURSING PRACTICE

AUTONOMY, ACCOUNTABILITY, ASSERTIVENESS AND LEGAL CONSIDERATIONS IN NURSING

INTRODUCTION
A profession is a group that requires specialized education and intellectual knowledge. As nursing continues to evolve many questions are also arising regarding its autonomy, accountability and legal liabilities. A profession is only as good as its individual members. Every member of the profession must practice as a professional and contribute to nursing as a profession. Beginning nursing students should understand the significance of ascribing to professional attitudes and values and how their behavior can influence the publics view of the nursing profession. As professionals, nurses are accountable for providing quality care

AUTONOMY
It is an ethical principle upholding the exercise of personal choice. The principle of autonomy stems from the action of respect for persons. It is a freedom to decide and act (Hicks, 2003) Autonomy means the practioners have control over their own functions in the work setting. Autonomy involves independence, a willing ness to take risks, self determination and self regulation. The autonomous practioner is also obligated to collaborate with others for benefit of the patient. Autonomy means the freedom and authority to act independently and control ones own life and the lives of others. Example An autonomous nurse might make adjustment about a clients possible health problems but would work with the client to identify the clients perceptions and priorities. ADVANTAGES OF AUTONOMOUS NURSING PRACTICE Autonomy consistent with the scope of nursing practice will maximize the effectiveness of nurse. With autonomy a professional nurse can make an independent decision about client care. Autonomy is not an absolute, but occurs in degrees. It increases innovations in nursing, increased productivity, higher nurse retention and greater client satisfaction. The nurse respects the client and the choices that the client may take. Example A nurse has the autonomy to develop and implement a discharge teaching plan based on specific client needs who has been hospitalized.

ACCOUNTABILITY
Nurses were legally liable for their actions or the omissions of necessary actions but often are unaware of it. At the turn of 21 st centuary, accountability has assumed importance and visibility it never before possessed. It refers to being answerable to someone for something one has done. It means providing an explanation to self, to the client, to the employing agency and to the nursing profession. (A N A, 1985) It is the state of being responsible and answerable for those behaviours and their outcomes that are included in ones professional role. DOMAINS OF ACCOUNTABILITY A professional nurse is accountable in several domains. That include, Professional accountability Legal accountability Ethical accountability Individual accountability Organizational accountability Professional accountability The nurse has the responsibility to the client to be competent, to render nursing services in accordance with standards of nursing practice and to adhere to professions ethical code. The public trusts that a registered nurse will have appropriate knowledge and skills to render the services offered. A registered nurse is accountable for acquiring the knowledge and skill to render the nursing care. Organizational accountability Organization is the means by which members of a profession join together to promote and protect the profession. Professional regulation is the process by which nursing ensures that its members act in the public interest by providing a unique service that the society has entrusted to them. (A N A, 1995) Professional regulation is the responsibility of professional organizations. Professional standards are authoritative statements developed by the profession by which the quality of practice service and education can be judged. ( A N A,1991) So each nurse is accountable for their professional activities to the respective organizations. Legislative accountability Legislation defines the legal rights granted to the profession by the public.

The Nurse Practice Act defines the legal scope of practice within a state or territory, authorize state boards of nursing to interpret the legal boundaries of safe nursing practice. (A N A,1995) Individual accountability Professional nurse must understand the rules and regulations and standards of practice adopted and should be active participant. This can be by, Continued competency Professional development

ASSERTIVENESS
Assertiveness is the ability to express yourself and your rights without violating the rights of others. Assertiveness comprises respect for others, respect for yourself, self awareness and effective, clear and consistent communication. (Darley,2002) It means that we have respect both ourselves and for others. An assertive person effectively influences, listens and negotiates so that others choose to cooperate willingly. Techniques of Assertiveness Be direct. Deliver your message directly to the person for whom it is intended. Own your message You can acknowledge ownership with personalized statements. Ask for feedback Asking for feedback can encourage others to correct any misinterpretations you may have as well as others realize that you are pressing an opinion. Stop apologizing all the time. Dont be self-deprecating, Self deprecating is belittling or undervaluing oneself excessively modest. Act confident, even if you are not confident. Advantages of assertiveness Express feelings and motions confidently, spontaneously and honestly. It encourages a sense of self assurance. Stand up for your own rights and experience self respect. More independence. Make decisions and control the life more effectively than others. Deal betterly with criticism and manipulation by others. Get treated as an individual with special values, skills and needs. It produces feelings of security, competency, power, optimism and professionalism. Able to deal change, negative conditions in both personal and professional life, conflict and stress.

 Consider yourself strong and face responsibilities.

LEGAL CONSIDERATIONS IN NURSING

The word law is derived from an Anglo- Saxon term meaning That which is laid down or fixed. There are two types of law 1) Public law which deals with an individuals relationship to the state. 2) Civil law which deals with the relationship between individuals. Public law It can be, Constitutional law developed by legislative bodies. Administrative law developed by groups who are appointed to administrative agencies. Criminal law refers to acts or offenses against the welfare or safety of the public. Two types of crimes, Felony Crime of a series nature punishable by imprisonment in a state penitentiary at hard labour or by death, punishment more than one year. Misdemeanor Offense that is less serious, punished by fine or sentence to a local prison for less than one year. Civil law It can be, Contract law is the enforcement of agreements among private individuals. Tort law is the enforcement of duties and rights among individuals independent of contractual agreements. Judicial law all of states lower units must adhere to the interpretations and procedures specified by the states supreme or highest court. Tort is a civil wrong committed on a person or property stemming from either a direct invasion of some legal right of the person. Unintentional tort a) Negligence b) Malpractice Intentional tort a) Assault b) Battery c) False imprisonment d) Invasion of privacy, e) Defamation

f) Fraud.

LEGAL LIABILITY IN NURSING

When the nurse fails to meet the legal expectations of care, the client can initiate action if harm is incurred by the client. Malpractice Refers to the behaviors of a persons wrongful conduct, improper discharge of professional duties or failure to meet the standards of acceptable care, which result in harm to another person. Negligence It is the failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance. Informed consent It is a legal written document obtained, that the client understands the reason for the proposed interventions and its benefits and risks and agrees to the treatment by signing a consent form. Informed consent is a process consisting of information and consent, not merely signing of a form. Obtaining the informed consent requires client teaching by the health care provider. A nurse may witness a clients signing of a consent form or may be responsible for making sure the signed form is in the chart. Assault It is a stated intent to touch a person in an offensive, insulting or physically intimidating manner. Battery It is the touching of another person without the persons consent. False imprisonment It occurs when clients are made to wrongfully believe that they cant leave from a place. Example Telling a client not to leave from hospital, before paying bill and using physical restraints. Restraints or seclusion It shows the rights of the client and responsibilities of a health care provider regarding the use of both physical and chemical restraints. Restraints are legal only if they are necessary to protect the client or other from harm and it should have the physicians order.

Privacy and confidentiality Nurses are accountable for respecting the clients right to privacy. Nurses must obtain the clients permission before disclosing any information regarding the client, going through the clients personal belongings, performing procedures and photographing the client. Defamation It occurs when information is communicated to a third party that causes damage to someone elses reputation either in writing (libel) or verbally (slander) Example Giving out inaccurate information from the medical record; discussing clients, families or visitors in public areas; or speaking negatively about co workers. Fraud It results from a deliberate deception intended to produce unlawful gain. Example Ill-legal billing, overcharging for services.

LEGISLATION AFFECTING NURSING

There are legal as well ethical implications inherent in nursing practice which require nurses to know and comply with the specific existing health care laws and regulations. ADVANCE DIRECTIVES Patient Self Determination Act (PSDA- 1990) explains the advance directives. It is a written document that s recognized under state law and is related to the provision of such care when the individual is incapacitated. It include, Living will It is a series of instructions regarding the withholding, withdrawing or implementing of life sustaining medical care in the event of terminal illness. Durable power of attorney for health care It is a private legal relationship created in which one person grants another person (proxy) the authority to make decisions regarding the health care for the person if he is mentally unable to make decisions as a result of an accident, illness or mental incapacity. ABORTION Health care agencies and practioners in various states may be required to report abortions performed as well as other information about the client ,the procedure and any resulting complications. GOOD SAMARITAN ACT

Law that provide protection to health care providers by ensuring immunity from civil liability when assistance is provided at the scene of an emergency when the caregiver does not intentionally or recklessly cause client injury.

LEGAL RESPONSIBILITIES OF A PROFESSIONAL NURSE

Nurse are legally responsible to practice nursing as a set forth in nurse practice acts and professional standards of care. There are several roles performed by the nurses: Render care based on their education, experiences and standards. Supervise and evaluate aspects of care that have been delegated to licensed and non licensed care givers. Document the care the client receives. Maintain clinical competency. Do the expert witness role. Nurses should know which situations have to be reported because each state has its own policies. Thorough with institutional policies.

CONCLUSION
A professional nurse must have adequate knowledge about legal responsibilities, autonomy and accountability. Nursing practice, education and research provide many opportunities for the professional nurse to take legal responsibilities.

BIBLIOGRAPHY
Catalano T.Joseph (2007),Nursing now, todays issue tomorrows trends , 1st edition, F.A Devis company, Philadelphia, pp-274-278. Leddy Susan, Pepper Mar (1998),Conceptual bases of professional nursing, 1st edition, Lippincott publishers, Philadelphia, pp- 325-343. Potter A Patricia, Perry. G. Anne (2005). Fundamentals of nursing, 6 th edition, Mosby publishers, pp-389-391.

SUBJECT : ADVANCED NURSING PRACTICE UNIT : 1

AUTONOMY, ACCOUNTABILITY, ASSERTIVENESS AND LEGAL CONSIDERATIONS IN NURSING

(SEMINAR)

CODE OF ETHICS AND PROFESSIONAL CONDUCT

INTRODUCTION
Ethics is the science relating to moral actions and ones value system. Ethics is concerned with motives and attitudes and the relationship of these attitudes to the good of the individual. Ethics have always been an integral part of nursing. Nursing ethics provide the standards for professional behaviour and is the study of principles of right and wrong conduct for nurses.

CODE OF ETHICS
Code of ethics is a set of ethical principles that are accepted by all members of a profession. A professions ethical code is a collective statement about the groups expectations and standards of behaviour .Codes serve as guidelines to assist nurses and other professional groups when questions arise about correct practice and behaviour.

NURSING CODE OF ETHICS

Nursing ethics state the duties and obligation of nurses to their clients, other health professionals, the profession and the community. Nursing ethics provide the standards for professional behaviour and is the study of principles of right and wrong conduct for nurses. International council of Nurses (ICN) , American Nurses Association (ANA) and Canadian Nurses Association(CAN) have established widely accepted codes that professional nurses attempt to follow.

EVOLUTION OF ICN CODE OF ETHICS

Nursing profession uses codes for Nurses: Ethical concepts Applied to Nursing as its guide for professional conduct. This code is adopted and published by the ICN. The first such Code of Ethics, called the International Code of Nursing Ethics, was adopted by the Grand council of the International Council of Nurses at Sao Paulo, Brazil in 1953. It was later revised in Frankfurt, Germany in 1965 and then became known as the ICN Code of Ethics.

The most recent revision in 1973 took place in Mexico and resulted in the present Code for Nurses. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005.

PURPOSES
Code of Ethics serve as a means of self-regulation and a source of guidelines for individual behaviour and responsibility. It can be used to prevent a nurse from practicing if her/his conduct is poor and clearly below the standards set by the Code. It can be used to protect the nurse who is falsely accused of doing something wrong. It helps teachers to know what must be taught in the education of the nurse. It can also be used as a guide for direction when a legal action must be taken in a law suit.

THE ICN CODE OF ETHICS FOR NURSES

An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005. PREAMBLE Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups. 2 THE ICN CODE The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct.

ELEMENTS OF THE CODE 1. NURSES AND PEOPLE The nurses primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgment in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction. 2. NURSES AND PRACTICE The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgment regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people. 3. NURSES AND THE PROFESSION The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organisation, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

4. NURSES AND CO-WORKERS The nurse sustains a co-operative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a coworker or any other person. SUGGESTIONS FOR USE OF THE ICN CODE OF ETHICS FOR NURSES The ICN Code of Ethics for Nurses is a guide for action based on social values and needs. It will have meaning only as a living document if applied to the realities of nursing and health care in a changing society. To achieve its purpose the Code must be understood, internalised and used by nurses in all aspects of their work. It must be available to students and nurses throughout their study and work lives.

BASIC ETHICAL PRINCIPLES

International Council of Nurses proposed some basic ethical principles. They are to be followed by each members of our profession. Ethical principles actually control professionalism nursing practice much more than to ethical theories. Principles are the moral norms that nursing, as profession both demands and strives to implement to every day clinical practice. So the nurse should consider them when making decisions are as follows. Respect for persons, Respect for autonomy. Respect for freedom. Respect for beneficence. Respect for non-maleficence. Respect for veracity. Respect for justice. Respect for rights. Respect for fidelity. Confidentiality. Accountability. Responsibility.

RESPECT FOR PERSONS It directs individuals to treat themselves and other, with a respect inherent to mans humanness. It requires recognition on a sense that all share a

common human destiny. The respect to persons need to be simplified as it affects nursing practice.

ACCOUNTABILITY Accountability refers to the ability to answer for ones own actions. The nurse balances accountability to the client, the profession, the employer and society. Accountability means being answerable for acts carried out in the performance of ones professional role. When one is answerable, it places the responsibility for the outcomes of nursing care directly on the practitioner. Nurses are also becoming more responsible in answering to patients, head nurses, and physicians for the quality of nursing care they provide. Domains of accountability are Professional accountability Organizational accountability Legal accountability Individual accountability RESPECT FOR AUTONOMY Autonomy is defined as the freedom to make prudent and binding decisions consistent with the scope of ones practice. It is also freedom to implement those decisions. Respect for anothers autonomy is fundamental to the practice of health care. It serves to justify the inclusion of clients in all aspects of decision making regarding their health care. RESPECT FOR FREEDOM This principle of individual freedom suggests that patients be exempt from control by others to select and pursue personal health goals .Nurses as a group believe that patient should have greater freedom of choice within the nations health care system. This principle should be observed by staff nurses when planning patient care; by nurse manger when leading subordinates. BENEFICENCE Beneficence refers to taking positive reactions to help others. The practice of beneficence encourages the urge to do good for others. It dictates that a person is obliged to help others to advance their legitimate and important interests. Commitment to beneficence helps to guide difficult decisions where in the benefits of a treatment may be challenged by risks to the clients well-being or dignity. NON-MALEFICENCE

Non- maleficence is the avoidance of harm or hurt. In health care ethics it is important to remember that ethical practice involves not only the will to do good, but also the equal commitment to do no harm.The standards of nonmaleficence promotes a continuing effort to consider the potential for harm even when it may be necessary to promote health.

VERACITY Veracity concerns truth telling and incorporates the concept that individuals should always tell the truth. It requires professional care-givers to provide with accurate, reality based information about their health status and care or treatment prospection. Truth telling is an ethical concern for nurses, because truth is the basis for mutual trust between patient and nurse, and trust is the basis for patients hope of benefit from nursing services. Nurse managers use this principle when they give all the facts of a situation, truthfully and assist their employees to make decisions. JUSTICE Justice concerns the issue that persons should be treated equally and fairly. This principle of justice requires treating others fairly and giving persons their due. The following problems complicate the application of justice. a) Not everyone is equal in everyway, sometimes there are situations in which it seems that one person should receive a greater or lesser share than another. b) Resources are limited. There is not always enough for each person to receive an equal share. FIDELITY Fidelity is keeping ones promises or commitments. The principle of fidelity holds that a person should faithfully fulfill his duties and obligations. Fidelity is important in a nurse because a patients hope for relief and recovery rests on evidence care givers conscientiousness. CONFEDENTIALITY Confidentiality is the duty to respect privileged information. The principle of confidentiality provides that care givers should respect a patient need for privacy and use personal information about him or her only to improve care. Nurses should practice confidentiality to decrease patient vulnerability and share from wide spread knowledge of personal information divulged during care.

CONCLUSION
In professional practice such as nursing, a code of ethics provides guidelines for safe and compassionate care. Nurses and other health care professionals agree to national code of ethics that define practice and offer to the public a definition of professional practice standards. A professional nurse is

expected to follow Code of Ethics, which represents the whole nursing profession to the public.

BIBLIOGRAPHY
Catalano. T. Joseph (2007). Nursing now, Todays issue, Tomorrows trends, 1st edition, F.A Devis company, Philadelphia, pp- 274- 278 Potter. A. Patricia, Perry G. Anne (2005). Fundamentals of Nusing,6 th edition, Mosby publishers,pp -389- 391. Zwemmer J Ann (1980). Professional adjustment and ethics for nurses in India, 1st edition, B. I Publishers, pp 95- 116.