1. Legal and Ethical Issues in Maternal/Newborn and Women’s Health
Developed by
D. Ann Currie , R.N. , M.S.N.

2. LEGAL CONSIDERATIONS GENERAL LEGAL CONCEPTS ARENAS FOR CONSIDERATION
LITIGATION
RISK MANAGEMENT
QUALITY ASSURANCE
DOCUMENTATION
CLINCAL EXAMPLES OF COMMON LEGAL ISSUES

3. GENERAL LEGAL CONCEPTS
LAW CAN BE DEFINED AS”THOSE RULES MADE BY HUMANS WHICH REGULATE SOCIAL CONDUCT IN A FORMALLY PRESCRIBED AND LEGALLY BINDING MANNER.”(BERNZWEIG)

4. FUNCTIONS OF THE LAW IN NURSING
THE LAW SERVES A NUMBER OF FUNCTIONS IN NURSING:
IT PROVIDES A FRAMEWORK FOR ESTABLISHING WHICH NURSING ACTIONS IN THE CARE OF THE CLIENTS ARE LEGAL
IT DIFFERENTIATES THE NURSE’SRESPONSIBILITIES FROM THOSE OF OTHER HEALTH PROFESSIONAL

5. CONT. FUNCTIONS
IT HELPS ESTABLISH THE BOUNDARIES OF INDEPENDENT NURSING ACTION.
IT ASSISTS IN MAINTAINING A STANDARD OF NURSING PRACTICE BY MAKING NURSES ACCOUNTABLE UNDER THE LAW.

6. SOURCES OF LAW
CONSTITUTION
LEGISLATION (STATUTES)
COMMON LAW

7. TYPES OF LAWS PUBLIC LAW- CRIMINAL LAW PRIVATE LAW-CIVIL LAW
CONTRACT LAW
TORT LAW

8. ARENAS OF LEGAL CONSIDERATION
PERSONAL PROFESSIONAL PRACTICE
CLIENT CARE AND ADVOCACY

9. LEGAL CONSIDERATIONS IN PERSONAL PROFESSIONAL PRACTICE
SCOPE OF PRACTICE
STANDARDS OF CARE
LICENSURE
COLLECTIVE BARGAINING

10. SCOPE OF PRACTICE THE NURSE PRACTICE ACT----
BROAD DEFINITION OF PERMISSIBLE BOUNDARIES OF PRACTICE WITHIN A STATE.
DISTINGUISHES NURSING PRACTICE FROM THE PRACTICE OF OTHER HEALTH PROFESSIONALS

11. SCOPE OF PRACTICE
EXCLUDES UNTRAINED OR UNLICENSED INDIVIDUALS FROM PRACTICING NURSING.
RULES AND REGULATIONS PROMULGATED BY STATE BOARDS OF NURSING PROVIDE OFFICIAL INTERPRETATION OF NURSING ACTS.

12. SCOPE OF PRACTICE
CORRECT INTERPRETATION AND UNDERSTANDING OF STATE PRACTICE ACTS ENABLES THE NURSE: TO PROVIDE SAFE CARE WITHIN THE LIMITS OF NURSING PRACTICE AND TO AVOID THE RISK OF BEING ACCUSED OF PRACTICING MEDICINE WITHOUT A LICENSE
READ AND KNOW THE NURSE PRACTICE ACT ****.

13. STANDARDS OF CARE DEFINITION:
MINIMUM CRITERIA FOR COMPETENT,PROFICIENT DELIVERY OF NURSING CARE.
USED TO EVALUATE THE QUALITY OF CARE PROVIDED
FORMULATED FROM SKILLS AND KNOWLEDGE COMMONLY POSSESSED BY MEMBERS OF

14. CONT. A PROFESSION….NURSES.
IDENTIFY HEALTH,DEMOGRAPHIC,ENIRONMENTAL,AND PSYCHOSOCIAL PARAMETERS OF CARE
REFLECTS CURRENT KNOWLEDGE IN THE FIELD,AND,THEREFORE,ARE DYNAMIC AND SUBJECT TO CHANGE.

15. USES OF STANDARDS OF CARE
CRITERION FOR DETERMINING IF A NURSE HAS VIOLATED THE STATE -NURSE PRACTICE ACT.
CRITERION FOR DETERMINING IF A NURSE HAS VIOLATED STATE OR CITY CRIMINAL CODES
CRITERION ELEVATING NURSING PRACTICE TO A PROFESSIONAL LEVEL.

16. INTERNAL STANDARDS OF CARE
INDIVDUAL
INSTITUTIONAL
SET BY ROLE AND EDUCATION OF THE NURSE: JOB DESCRIPTION,EDUCATION,AND EXPERTISE
SET BY INDIVIDUAL INSTITUTIONS: POLICIES AND PROCEDURES.

17. EXTERNAL OR NATIONAL STANDARDS OF CARE
EXTERNAL BECAUSE THEY SUPERCEDE INDIVIDUAL PRACTITIONERS AND INSTITUTIONS.
BROADER THAN LOCALITY RULES: STANDARDS OF CARE VEIWED FROM THE PERSPECTIVE OF CARE WITHIN A GEOGRAPHIC AREA.

18. CONT. EXTERNAL STANDARDS OF CARE
BASED ON REASONABLENESS AND AVERAGE DEGREE OF SKILL,CARE, AND DILIGENCE PRACTICED BY MEMBERS OF THE PROFESSION ACROSS THE NATION.
NURSES IN A VARIETY OF SETTINGS AND LOCALS MUST MEET THE SAME STANDARDS: HOMES,BIRTHING CENTERS,HOSPITALS ETC.

19. CONT. ETERNAL STANDARDS OF CARE
STANDARDS ESTABLISHED BY:
STATE BOARDS OF NURSING THROUGH NURSE PRACTCE ACTS OR PROMULGATED RULES AND REGULATIONS.
PROFESSIOAL ORGANIZATIONS: ANA,ICN,OR CONGRESS FOR NURSING PRACTICE.

20. CONT. EXTERNAL STANDARDS OF CARE
SPECIALITY NURSING ORGANIZATIONS:AWHONN,NANN, ACNM.
FEDERAL ORGANIZATIONS AND GUIDELINE: JCAHO AND MEDICARE RULES.

21. STANDARD OF CARE NEGLIGENCE AND MALPRACTICE
NEGLIGENCE- IT IS OMITTING AN ACT OR DEVIATION FROM THE STANDARD OF CARE THAT A REASONABLY PRUDENT PERSON WOULD NOT OMIT OR COMMIT UNDER SIMILAR CIRCUMSTANCES.
MALPRACTICE- IT IS A NEGLIGENT ACTION OF A PROFESSIONAL

22. ELEMENTS OF NEGLIGENCE
THERE WAS A DUTY TO PROVIDE CARE.
THE DUTY WAS BREACHED.
INJURY OCCURRED.
THE BREACH OF DUTY CAUSED INJURY

23. EXAMPLES OF NEGLIGENCE
EXAMPLES OF OMISSION: FAILING TO GIVE A MEDICATION, FAILING TO ASSESS PROPERLY,FAILING TO NOTIFY A PHYSICIAN OF A CHANGE IN A CLIENT”S CONDITION OR STAUS.
EXAMPLES OF COMMISSION:GIVING WRONG MEDICATION OR TO WRONG CLIENT

24. CONT.
PLACING INFANT IN WRONG CRIB OR GIVING INFANT TO WRONG MOTHER.

25. CONT.
NURSES NOT MEETING APPROPRIATE STANDARDS OF CARE COULD BE SUBJECT TO ALEGATIONS OF NEGLIGENCE OR MALPRACTICE.

26. NURSE’S RESPONSILITY IN PREVENTING NEGLIGENCE AND MALPRACTICE
OBTAIN AND MAINTAIN CURRENT INFORMATION REGARDING THE STATE NURSE PRACTICE ACT- GET A COPY AND READ IT AND KNOW IT..READ PUBLICATION FROM THE STATE (BON), VISIT WEB SITE FOR BNE INFORMATION AND ATTEND BNE WORKSHOPS.

27. CONT. NURSE RESPONSIBLITY
OBTAIN AND MAINTAIN CURRENT INFORMATION ON INTERNAL AND EXTERNAL STANDARDS OF PRACTICE,
SEEK CONTINUING EDUCATION TO REMAIN CURRENT IN SPECALITY AREAS
USE THE NURSING PROCESS WHEN GIVING CLIENT CARE.

28. CONT. NURSE’S RESPONSIBILITY
DEVELOPE A POSITIVE, EMPOWERING RELATIONSHIP WITH CLIENTS---SEE CLIENTS AS AN IMPORTANT MEMBER OF THE HEALTH TEAM.
BE THROUGH IN COMPLETING AND REPORTING ASSESSMENTS AND IMPLEMENTING CARE.

29. CONT NURSE’S RESPONSIBLITY
MAINTAIN CLEAR, CONCISE, ACCURATE, COMPLETE, AND LEDGIBLE DOCUMENTATION.
QUESTION APPROPRIATENESS OF CARE WHEN HARM CAN BE DONE TO CLIENT.
CHECK MEDICAL ORDERS FREQUENTLY.
USE CHAIN OF COMMAND.

30. LEGAL CONSIDERATIONS FOR CLIENT CARE
HEALTHCARE REFORM
MANAGED CARE
SHORTENED HOSPITAL STAYS
UNLICENSED ASSISTIVE PERSONNNEL(UAP)
NURSE’S ROLE AS CLIENT ADVOCATE.

31. Healthcare reform
The USA leads the world in healthcare spending, yet has one of the highest infant mortality rates among the industrialized nations……..
One of the primary factors related to infant mortality(deaths under one year of age per 1000 live births) is an increase in the delivery of low birth weight infants, which is linked to lack of prenatal care.

32. Healthcare Reform Barriers to access to prenatal care
1) Costs of health care
2) Limited financial resources
3)Uncoordinated service systems
4) Individual behaviors and beliefs concerning health care
5)Bureaucratic obstacles, such as complicated, lengthy forms for Medicaid

33. HEALTHCARE REFORM Barriers to prenatal care
6) Unavailability of maternal services in certain parts of the country
7) Underfunded and overcrowded publicly supervised clinics
8) Difficulty in recruiting and retaining healthcare providers in publicly subsidized clinics

34. Healthcare reform Barriers to prenatal care
9) Lack of coordinated services for needy individuals
10) Inaccessibility to prenatal services because of transportation, location, and lack of child care facilities.
11) Other….

35. HEALTHCARE REFORM
Federal and state governments, through policies and legislation, have begun to implement strategies to resolve these barriers by:
1) Broadening health insurance coverage for childbearing women and infants
2) Improving coordination and funding of public programs

36. Healthcare Reforms 3) Simplifying bureaucratic procedures
4) Increasing the number of maternity care providers
5) Establishing a national council on children and health
6) Raising public awareness throughout the country
7) Other…..

37. HEALTHCARE REFORM
NEED TO CONTINUE to seek reform to further control costs, improve access to healthcare, and improve quality of healthcare

38. MANAGED CARE Private sector solution for decreasing healthcare costs
1) Health insurance plans that combine: delivery of healthcare services, financing of those services, controlling the use of services.
2) Philosophy of managed care organizations includes:

39. Managed Care
Cont. Health promotion and disease prevention, desire to avoid serious disease and costly treatment services
3)To meet expenses and make a reasonable profits
4) Creates a climate in which providers have: little time and few resources with which to provide care and financial

40. MANAGED CARE
CONT. -DISINCENTIVES FOR PROVIDERS TO GIVE ADEQUATE SERVICES TO THEIR CLIENTS.
5) CONSEQUENCES : FEWER EXPENSIVE TESTS OR COSTLY PROCEDURS PERFORMED, SHORTENED HOSPITAL STAYS AND INCREASED USE OF UNLICENSED HEALTHCARE WORKERS.

41. SHORTENED HOSPITAL STAYS
During the early to mid-1990 hospital stays after birth were shortened to 24 hours or less….
Consequently, there was not enough time for maternal and parental teaching regarding self care and infant care- problems in infant care and health developed, breast-feeding problems, and self care problems in the mothers.

42. SHORTENED HOSPITAL STAYS
Several states passed laws requiring longer stays for maternity and neonatal clients..
U.S. Congress passed Senate Bill 969, the Newborns’ and Mothers’ Protection Act of 1996:1) Set a national standard requiring health insurance and employer-provided benefit plans to cover minimum hospital stay: 48hrs-vaginal delivery,

43. SHORTENED HOSPITAL STAYS
96 hrs for c/s, early discharge with home health care..within hrs of discharge.
2) Even with federal law mandating a longer postpartum stay, nurses are still responsible for: verbal and written instructions about infant and self-care, and s/s indicating problems and what to do, and f/u visit.
In Texas nurses must teach about PP depression

44. SHORTENED HOSPITAL STAYS
Cont. evaluation of parents’ learning, recommending timely follow-up care, incliding a home visit,whenmom seems at risk after a longer stay.

45. UNLICENSED ASSISTIVE PERSONNEL (UAP)
UAPs are healthcare workers who have no defined body of knowledge or educational preparation upon which to base their practice
Uncreditentialed
No state or federal regulatory body to validate their competence

46. UAPS
Nurses are responsible for the delegation of tasks to UAPs…see Texas BON guidelines for delegation .
UAPs can perform repetitive tasks…which are clearly defined and for which they have been trained.
Nurses should obtain information on UAPs’ training and skills prior to delegating tasks.

47. UAPS
Inappropriate delegation to UAPs increases the nurse’s liability and may jeopardize the nurse’s license.
What should not be delegated to UAPs: Essential nursing processes of assessing,diagnosing of a problem, planning client care, implementing that care, and evaluating the outcomes.And judgements about client status.

48. NURSE’S ROLE AS CLIENT ADVOCATE
Maintain current information about issues critical to client care….
Educate clients and other significant persons about such issues…
Become involved in the political process as an advocate for quality healthcare for all healthcare recipients.
Other…...

49. LITIGATION

50. RISK MANGEMENT

51. QUALITY ASSURANCE

52. DOCUMENTATION

53. CLINICAL EXAMPLES OF COMMON LEGAL ISSUES

54. ETHICAL CONSIDERATIONS
ETHICS IS BASED ON A RESPONSIBILITY OR DUTY MODEL EXAMINING WHAT OUR BEHAVIOR OUGHT TO BE IN RELATION TO OURSELVES, OTHER HUMAN BEINGS,AND THE ENVIRONMENT

55. ETHICS
ETHICS INCORPORATES FACTORS SUCH AS: RISKS.BENEFITS,OTHER RELATIONSHIPS, CONCERNS, AND THE NEEDS AND ABILITIES OF PERSONS AFFECTED BY AND AFFECTING DECISIONS.
IT IS SUBJECT TO PHILOSOPHICAL, MORAL, AND INDIVIDUAL INTERPRETATIONS.

56. ETHICAL PRINCIPLES SHOULD BE USE IN CLINICAL PRACTICE RESPECT AUTONOMY
BENEFICENCE
NONMALEFICENCE
VERACITY: DUTY TO TELL THE TRUTH

57. CONT. ETHICAL PRINCIPLES
FIDELITY: DUTY TO KEEP ONE’S PROMISE
JUSTICE
CONFIDENTIALITY
INFORMED CONSENT
UNIVERSALITY

58. ETHICAL DECISION-MAKING FRAMEWORK
MORAL
M:ESSAGE THE DILEMMA
O:OUTLINE THE OPTIONS
R:RESOLVE THE DILEMMA
A:ACT BY APPLYING THE CHOSEN OPTION
L:LOOK BACK AND EVALUATE THE ENTIRE PROCESS

59. MORAL M: MESSAGE THE DILEMMA IDENTIFY AND DEFINE ISSUES IN THE DILEMMA
DETERMINE WHO OWNS THE PROBLEM,THE INFORMATION,THE DECISION, AND THE CONSEQUENCES OF IT.

60. CONT. M ESTABLISH THE FACTS AS BEST AS POSSIBLE.
CONSIDER THE OPTIONS,VALUES, AND MORAL POSITION OF THE MAJOR PLAYERS.
IDENTIFY VALUE CONFLICTS.

61. O: OUTLINE THE OPTIONS
EXAMINE ALL OPTIONS FULLY,INCLUDING THE LESS REALISTIC AND CONFLICTING ONES
IDENTIFY PROS AND CONS OF ALL THE OPTIONS
FULLY COMPREHEND THE OPTIONS AND ALTERATIVES AVAILABLE/

62. R: RESOLVE THE DILEMMA REVIEW THE ISSUES AND OPTIONS
APPLY ETHICAL PRINCIPLES TO EACH OPTION
DECIDE THE BEST OPTION FOR ACTION ON THE VIEWS OF ALL THOSE CONCERNED

63. A: ACT BY APPLYING THE CHOSEN OPTION
IMPLEMENT THE CHOSEN OPTION

64. L: LOOK BACK AND EVALUATE THE ENTIRE PROCESS
INCLUDING IMPLEMENTATION.
ENSURE THAT ALL THOSE INVOLVED ARE ABLE TO FOLLOW THROUGH ON THE FINAL OPTION
REVISE THE DECISION AS INDICATED,STARTING THE PROCESS WITH THE INITIAL STEP.

65. WHERE TO GET HELP TO MAKE AN ETHICAL DECISION.
Ethics committee in your organization…hospital.
Clergy
Ethics depart.
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66. ETHICAL CONSIDERATIONS IN MATERNITY NURSING
ASSISTED REPRODUCTION
ABORTION
FETAL OR EMBRYO RESEACH
CORD BLOOD BANKING
THE HUMAN GENOME PROJECT
GENETIC COUNSELING
FETAL RIGHTS VERSUS MATERNAL RIGHTS

67. NURSES’ RESPONSPONSIBLITIES
Learn to anticipate ethical dilemmas
Identify attitudes,values, and beliefs about ethical dilemmas taking into consideration the influence of cultural,religious, and social factors on the development of values.
Recognize the influence personal values have on care provided for clients by engaging in self-values clarification activities.

68. NURSES’RESPONSIBILTIES
Review and update theoretical bases: gather current information on technological advances and changing trends in maternity nursing, review ethical principles and practice codes in regard to new technology and trends, become familiar with the client’s knowledge base by reading lay literature related to maternity and neonatal advances

69. NURSES’ RESPONSIBILTIES
Attend cont. ed. Programs related to ethical issues and decision making-- participate in ethics committees with other healthcare professionals and inservice peers on ethical issues and decision making.
Review research journals regarding current trends in ethical decision making .comparing and contrasting the results with what is occurring in the clinical practice.

70. NURSES’ RESPONSIBILITES
Evaluate current social norms by following social,legal,religious, and political debates that may influence clinical decision making and quality care for clients experiencing dilemmas in the maternal, neontal, or women’s health areas.
Avoid judgements about the life decisions of others.

71. NURSES’S RESPONSIBILITIES
Aim to accept the values of others and their decisions regarding issues and provisions of care.
Don’t allow personal beliefs and values to interfere with provision of quality care.
Understand the legal implications of the issues
Develop appropriate strategies for ethical decision making.