LEGAL & ETHICAL ISSUES IN

PEDIATRIC INTENSIVE CARE UNIT

PREPARED BY
MRS. ANISHA MANE
• AIM- At the end of the seminar students are able to understand ethical
& legal issues in pediatric intensive care unit.

• OBJECTIVES - At the end of the seminar students are able to,

1. Define the key words .
2. List the need of ethics in nursing.
3. Explain principles of ethics.
4. Desribe utilitarianism.
5. Explain special considerations in the NICU
6. Explain the legal System
7. Explain the sources of law and Law in nursing.
8. Explain standard of care
9. Describe the legal issues in NICU
INTRODUCTION
• The Consumers are patients with complex needs. With increased
awareness of health care, health care facilities and Consumer
Protection Act, patients are getting aware about their rights. Nurses
also have now the expanded role. Issues which seem not feasible, and
ideal, may become practice with the change of time. These issues are
base for the future trends in care.
KEY WORDS
• Laws- Law is a system of rules that are created and enforced through
social or governmental institutions to regulate behavior.
• Values- In ethics, value denotes the degree of importance of some thing
or action, with the aim of determining what actions are best to do or
what way is best to live.
• Moral- It is concerned with the principles of right and wrong behaviour.
• Rights- Rights are legal, social, or ethical principles of freedom.
ETHICAL SYSTEM

• Ethics are the rules or principles that govern right conduct and are
designed to protect the rights of human beings.
• - Sister Nancy.
• Code of ethics is a guideline for performance and standards and personal
responsibility.
• -Lillie M S and Juanita Lee
NEED FOR NURSING ETHICS
• Helps the students/ RN to practice ethically
• Helps the nurse to identify the ethical issues in her work place
• Protecting patients right and dignity
• Providing care with possible risk to the nurses health
• Staffing patterns that limit the patients access to nursing care
• Ethical reasoning helps the nurse to respond to ethical conflicts
• Helps to differentiate right /wrong behavior
• Guide for a professional behavior
• Help teachers plan education.
• Prevent below standard practice.
PRINCIPLES OF ETHICS
• Ethical dialemmas can occure when any member of the health care
team, the patient, or the family members disagrees with the type,
course of treatment given to the patient.
 DECISION SCIENCE- Ethical decision making comprises two fields of the
study that do not fit comfortably together. The first field of the study is that of
decision science, or the rational consideration of problems and issues to find a
reasonable conclusion.
 Moral reasoning - The second field of the study used in ethical decision is that of
moral reasoning, which is based on religious and cultural beliefs and perspectives.
Moral reasoning often defines rational explanation but carries with it the power of
belief that is inexplicably tied to an individuals family, experiences, relationships,
values and religion.
Integration of moral reasoning and decision science

• The integration of decision science with moral reasoning engages nurses and other
health care professionals in the most difficult and complex issues in practice,
because they move those involved from a state of scientific certainty into a state of
uncertainty and instabiity.

• When the equilibrium of the normal state of security is upset, an individual feels
spiritually, emothionally, physically and intellectually stressed.
Utilitarianism
• There are no right or wrong action, but each possible course of action
is evaluated in comparison with all others.
• Parents use this frame of reference when considering the effect that the
neonates illness and condition will have on the family in both the near
and long term. for example, they may express concerns regarding the
familys financial stability, time constraints, alteration of personal and
professional goals, and the effect on the other children already present
in the family.
Special considerations in the NICU

• Neonatal nurses face special challenges when dealing with ethical

issues in their practice. The NICU environment is foreign and even
frightening to most parents, making them feel as though thay have
littel or no control over the care of their babys.
• Unclear information from a variety of health care providers, emotional
stress, and urgency of decisions converge together to cause a crisis in
the relationship between the parents and the health care team.
LEGAL SYSTEM

• Meaning of Legal –
Established by or founded upon law or official or accepted rules
• Sources of law
• Constitutional law: - It is a judgmental law. Law that governs
the state. It determines structure of state, power and duties.
• Common law:- It is a body of legal principles that evolved from
court decisions.
• Administrative law: - Rules and regulations established by
administrative agencies made by executives of government.
• Law in nursing
• Common law -Created by judicial decisions made in courts when individual
cases are decided
• Felony -Is a crime of serious nature that has a penalty of imprisonment for
greater than one year or even death
• Misdemeanor -Is a less serious crime that has a penalty of a fine or
imprisonment of less than one year
• Civil law -Protects the rights of individual persons within our society and
encourage fair and equitable treatment among people
• Contract Law - It is the enforcement of agreements among private individuals.
• Employment Contracts is an example of contract law under civil law
• Criminal law -Prevent harm to society and provides punishment for crimes
Standard of care

• Nurses today are evaluated by a national standard because advances in

communication, technology, transportation, and the law which have made obsolete
the “locality rule”.

• The locality rule permitted nurese to be judged according to the standard of care
evidenced by nurses working in the same geographic area.

• In addition, accredited school of nursing across the nation have similar currivula
and textbooks, and nurses attend similar continunig education conferences.
Institutional policies, procedures and protocols

• The hospital policies, procedures, and protocols also outline the standard of care.

• The policy establish the purposes for performing a procedure, whereas the
procedure is the guideline for how that procedure should be carried out.

• These guidlines must reflect the national and state standards of care, should be
reviewed at least annually.
Standards of professional organizations

• Professional associations represent the interests of nurses.

• Specialty oraganizations such as the National Association of Neonatal

Nurses.

• Associations of Womens Healh, Obstetrics and Neonatal Nurses.

• Association of Pediatric Nurse Associates and Practitioners have

adapted these standards to define the standards of care.
Legal issues in NICU
• Liability -

Today nurses are recognized as professionals who are responsible and

accountable for the care they give to the patients.

If the nurses is liable to the patient because of negligent conduct, that

the nurse can be held legally responsible for the harm caused to that
patient.
Scope of practice

• Each state has its own nurse practice act, composed of statutes passed by its
legislature & defining the boundaries of nursing practice.

• Theses laws vary from state to state in their demarcation of nursing practice.

• Neonatal nursing is considered a specially area of practice.

• Certification for neonatal nurse is available through several speciality

organizations. (ANA)
Advance Practice

• The health care delivery system involves neonatal advanced practice nurse
which can be found in hospitals, ambulatory care centers, and private practice.

• The advance practice nurse (APN) is often the only health care provder in
many rural areas.

• According to ANA , APNs are those who have further knowledge and practice
experiences that have prepared them for specialization, expansion, and
advancement in the practice role. ( Barnard 1994).
• Neonatal Nurse Practitioner-

• One of the most common APNs found in the tertiary care center.

• Is responsible for managing a caseload of neonatal patients with

general supervision, collaboration, and consultation from a physician.

• Is involved in education, consultaion , and research

• Will require masters degree for certification as of the year 2000.

Documentation

• It is a professional responsibility of the nurse to document on the medical record.

This will -
 Facilitate care
 Enhance continuity & co-ordination of care
 Assist in the evaluation of the patients response to treatment
 Provide a legal & official record of the care provided
 The medical record is used by the attorney as a tool provide evidence in legal
proceedings because it also verifies that the nures provides standard of care, also
routine care.
• The most common charting system in NICU are -

• Charting system containts nursing care plans, nursing database ,

flowsheets and progress notes.
Other medico - legal issues

• 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.
• If a nurse determine that a patient in any setting needs medical care, and she does
not do everything within power to obtain that care for the patient, you have
breached your duty as a nurse.
CONFIDENTIALITY

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

• 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.
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.
PATIENT SATISFACTION

• Patient satisfaction is an important and commonly used indicator for

measuring the quality in health care. Patient satisfaction affects
clinical outcomes, patient retention, and medical malpractice claims.

• ASSESSMENT OF QUALITY OF HEALTH CARE

• Patient as a consumer
• Today the patient sees himself as a buyer of health services. patient
satisfaction is an important tool for the success of their organization
and are regularly monitoring patient satisfaction levels among their
customers.
• SERVICE EXCELLENCE- Service excellence revolves around three
factors: doctor, patient, and organization.
• Doctor- He should do following-
• See the whole person
• Secure confidentiality and privacy
• Preserve dignity & Respond quickly
• Patient- Patients expect their doctors to keep up the timings, behave
cordially, and communicate in their language. They expect care, concern,
and courtesy in addition to a good professional job.
• Hospital

• There are certain areas where minimum requirements and

standards have to be maintained.
• Good telephone service
• Good office appearance
• Minimizing waiting time
• More doctor-patient interaction
• Proper patient education
• Feedback
• BENEFITS OF PATIENT SATISFACTION
• Patient satisfaction leads to customer (patient) loyalty.
• Improved patient retention
• Consistent profitability
• Increased staff morale with reduced staff turnover also leads to
increased productivity.
• Reduced risk of malpractice suits
• Accreditation issues are resolved.
• Increased personal and professional satisfaction
MANAGEMENT ISSUES

• It is a considerable challenge to meet the needs of the

organization, the needs of patients, and the needs of the nurse
employees.
TURNOVER

• Nurses faced with long work hours for relatively little pay have
few motivations to remain in one position and often seek
employment opportunities at competing hospitals and
neighboring clinics.
FUNDING

• An underfunded institution cannot attract and provide for the right professionals.
• When the medical institution's quality of staff and training standards must be
lowered because of budgetary concerns, the overall level of patient care is
unavoidably reduced.
• Workload
• Not only do nurse professionals work long hours and many days per week, but
nurse managers and leaders are also faced with an ever- increasing workload.
• Many nurses are unwilling to enter into the nurse management field because of
the added stress and responsibility.
• Issues regarding malpractice in nursing management -

• It can lead to several management problems. Improper use of

administration power, improper managing of supplies, staff, ward,
institution etc.

• Issues of delegation and supervision –

• The failure to delegate and supervise within acceptable standards of

professional practice.
RELATED RESEARCH
• Elina Aitamaa, (May 10, 2015) conducted a study on Ethical problems in
nursing management: The views of nurse managers .
• Nurse managers have responsibilities relating to the quality of care, the
welfare of the staff and running of the organization.
• Ethics plays significant role in these responsibilities. Ethical problems are
part of daily management, but research in this area is limited.
• The aim of this study was to identify and describe ethical problems nurse
managers encounter in their work to get more detailed and extensive view
of these problems.
• The data consisted of nine interviews with nurse managers at different
management levels in primary healthcare and specialized healthcare
organizations, and it was analysed by inductive content analysis.

• Four main categories were found: conflicts in practical situations, lack

of appreciation, disregard of problems and experienced inadequacy.

• Problems could also be divided to patient-related, staff-related,

organization-related and other problems.
• The findings correspond with results from earlier studies but add
knowledge of the nature and details of nurse managers' ethical
problems.
• New information is produced related to the ethical problems
with nurse managers' own courage, motivation and values.
• Nurse managers identified a variety of different ethical
problems in their work.
• This information is useful in the development of ethics in
nursing management.
Bibliography

1. Gupta P., Essential Pediatric Nursing, (4th edition), CBS Publishers

and distributors.

2. Ghai O. P. , Essential Pediatrics, (3rd edition), Interprint publishers.

3. Wong’s,Clinical Manual of Pediatric Nursing (7th edition). Mosby :

Elsevier Publications.