History of Nursing Law in the Philippines As nurses role expands, so does the legal accountability of the role itself

Early Beliefs, Practices and Care of the sick

1. 2.

Mary Johnston Hospital School of Nursing 1907 Philippines General Hospital school of Nursing 1910

College of Nursing 1. UST College of Nursing 1st College of Nursing in the Phils: 1877 MCU College of Nursing June 1947 (1st College who offered BSN 4 year program) UP College of Nursing June 1948 FEU Institute of Nursing June 1955 UE College of Nursing Oct 1958

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Early Filipinos subscribed to superstitious belief and practices in relation to health and sickness Diseases, their causes and treatment were associated with mysticism and superstitions Cause of disease was caused by another person (an enemy of witch) or evil spirits Persons suffering from diseases without any identified cause were believed bewitched by mangkukulam Difficult childbirth were attributed to nonos Evil spirits could be driven away by persons with powers to expel demons Belief in special Gods of healing: priest-physician, word doctors, herbolarios/herb doctors

2. 3. 4. 5. 1909

3 female graduated as qualified medical-surgical nurses 1919 The 1st Nurses Law (Act#2808) was enacted regulating the practice of the nursing profession in the Philippines Islands. It also provided the holding of exam for the practice of nursing on the 2nd Monday of June and December of each year. 1920

Early Hospitals during the Spanish Regime religious orders exerted efforts to care for the sick by building hospitals in different parts of the Philippines: Hospital Real de Manila San Juan de Dios Hospital San Lazaro Hospital Hospital de Aguas Santas Hospital de Indios Prominent personages involved during the Philippine Revolution 1. Josephine Bracken wife of Jose Rizal installed a field hospital in an estate in Tejeros that provided nursing care to the wounded night and day. Rose Sevilla de Alvaro converted their house into quanters for Filipino soldiers during the Phil-American War in 1899. Hilaria de Aguinaldo wife of Emlio Aginaldo organized the Filipino Red Cross. Melchora Aquino (Tandang Sora) nursed the wounded Filipino soldiers, gave them shelter and food. Captain Salomen a revolutionary leader in Nueva Ecija provided nursing care to the wounded when not in combat. Agueda Kahabagan revolutionary leader in Laguna also provided nursing services to her troops. Trinidad Tecson (Ina ng Biak na Bato) stayed in the hospital at Biac na Bato to care for the wounded soldiers.

1st board examination for nurses was conducted by the Board of Examiners, 93 candidates took the exam, 68 passed with the highest rating of 93.5%-Anna Dahlgren theoretical exam was held at the UP Amphitheater of the College of Medicine and Surgery. Practical exam at the PGH Library. 1921 Filipino Nurses Association was established (now PNA) as the National Organization Of Filipino Nurses PNA: 1st President Rosario Delgado Founder Anastacia Giron-Tupas 1953 Republic Act 877, known as the Nursing Practice Law was approved.

2. 3. 4. 5. 6. 7.

School Of Nursing 1. 2. St. Pauls Hospital School of Nursing, Intramuros Manila 1900 Iloilo Mission Hospital Training School of Nursing 1906 1909 distinction of graduating the 1st trained nurses in the Phils. With no standard requirements for admission of applicants except their willingness to work April 1946 a board exam was held outside of Manila. It was held in the Iloilo Mission Hospital thru the request of Ms. Loreto Tupas, principal of the school. 1. St. Lukes Hospital School of Nursing 1907;opened after four years as a dispensary clinic.

A.1.1. Early Beliefs and Practices (Diseases and their causes and treatment were shrouded with mysticism and superstitions.) 1.Beliefs about causation of disease:

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another person (an enemy or a witch) evil spirits

2.Belief that evil spirits could be driven away by persons with powers to expel demons.

Belief in special gods of healing, with the priest -physician (called word doctors) as intermediary. If they used leaves or roots, they were called herb doctors (herbolarios) Early Care of the Sick The early Filipinos subscribed to superstitious belief and practices in relation to health and sickness. Herb men were called herbicheros meaning one who practiced witchcraft. Persons suffering from diseases without any identified cause were believed bewitched by mangkukulam or mangagaway. Difficult childbirth and some diseases (called pamao) were attributed to nunos. Midwives assisted in childbirth. During labor, the mabuting hilot (good midwife) was called in. If the birth became difficult, witches were supposed to be the cause. To disperse their influence, gunpowder were exploded from a bamboo cane close to the head of the sufferer. Health Care During the Spanish Regime The religious orders exerted their efforts to care for the sick by building hospitals in different parts of the Philippines. The earliest hospitals were: Hospital Real de Manila (1577) it was established mainly to care for the Spanish kings soldiers, but also admitted Spanish civilians; founded by Gov. Francisco de Sande. San Lazaro Hospital (1578) founded by Brother Juan Clemente and was administered for many years by the Hospitalliers of San Juan de Dios; built exclusively for patients with leprosy. Hospital de Indios (1586) established by the Franciscan Order; service was in general supported by alms and contributions from charitable persons. Hospital de Aguas Santas (1590) established in Laguna; near a medicinal spring, founded by Brother J. Baustista of the Franciscan Order. San Juan de Dios Hospital (1596) founded by the Brotherhood of Misericordia and administered by the Hopsitaliers of San Juan de Dios; support was delivered from alms and rents; rendered general health service to the public. Nursing During the Philippine Revolution Josephine Bracken, wife of Jose Rizal- installed a field hospital in an estate house in Tejeros; provided nursing care to the wounded night and day Rosa Sevilla de Alvero- converted their house into quarters for the Filipino soldiers; during the Philippine-American War that broke out in 1899 Dona Hilaria de Aguinaldo- wife of Emilio Aguinaldo; organized that Filipino Red Cross under the inspiration of Mabini Dona Maria Agoncillo de Aguinaldo- second wife of Emilio Aguinaldo; provided nursing care to Filipino soldiers during the revolution, President of the Filipino Red Cross branch in Batangas Melchora Aquino (Tandang Sora) nursed the wounded Filipino soldiers and gave them shelter and food Capitan Salome a revolutionary leader in Nueva Ecija; provided nursing care to the wounded when not in combat Agueda Kahabagan- revolutionary leader in Laguna, also provided nursing services to her troops Trinidad Tecson (Ina ng Biak-na-Bato)- stayed in the hospital at Biak na Bato to care for wounded soldiers

Hospitals and nursing schools Iloilo Mission Hospital School of Nursing (Iloilo City, 1906) It was ran by the Baptist Foreign Mission Society of America. Miss Rose Nicolet, a graduate of New England Hospital for Women and Children in Boston, Massachusetts was the first superintendent for nurses. It moved from its present location to Jaro Road, Iloilo City in 1929. Miss Flora Ernst, an American nurse, took charge of the school in 1942. In April 1944 graduate nurses took the first Nurses Board Examination at the Iloilo Mission Hospital. Saint Pauls Hospital School of Nursing (Manila, 1907) The hospital was established by the Archbishop of Manila, Jeremiah Harty under the supervision of the Sisters of St. Paul de Chartres located in Intramuros. It provided general hospital services. It opened its training school for nurses in 1908, with Mother Melanie as superintendent and Miss Chambers as Principal. Philippine General Hospital School of Nursing (Manila, 1907) PGH began in 1901 as a small dispensary for Civil officers and Employees in the City of Manila and later grew as a Civil Hospital. In 1906, Mary Coleman Masters, an educator advocated for the idea of training Filipino girls for the profession of nursing with the approval of Government officials, she first opened a dormitory for Girls enrolled at the Philippine Normal Hall and the University of the Philippines. In 1907, with the support of Governor General Forbes and the Director of Health and among others, she opened classes in nursing under the Auspices of the Bureau of Education. Admission was based on an entrance examination. The applicant must have completed elementary education to the seventh grade. Julia Nichols and Charlotte Clayton taught the students nursing subjects. American physician also served as lecturers. In 1910, the Act No. 1976 modified the organization of the school placing it under the supervision of the Department of Health. The Civil Hospital was abolished and the Philippine General Hospital was established. St. Lukes Hospital School of Nursing (Quezon City, 1907) The hospital is an Episcopalian Institution. It began as a small dispensary in 1903. In 1907, the school opened with three girls admitted. These three girls had their first year in combined classes with the PGH School of Nursing and St. Pauls Hospital School of Nursing. Miss Helen Hicks was the first principal. Mrs. Vitaliana Beltran was the first Filipino superintendent of nurses and Dr. Jose Fores was the first medical director of the hospital. Mary Johnston Hospital and School of Nursing (Manila, 1907) It started as a small dispensary on Calle Cervantes (now Avenida). It was called the Bethany Dispensary and funded by the Methodist Mission for the relief of suffering among women and children. In 1907, Sister Rebecca Parrish together with registered nurses Rose Dudley and Gertude Dreisbach, organized the Mary Johnston School of Nursing. The nurses training course began with three Filipino young girls fresh from elementary as their first students. Philippine Christian Mission Institute Schools of Nursing The United Christian Missionary Society of Indianapolis, Indiana- a Protestant organization of the disciples of Christ operated three schools of nursing: Sallie Long Read Memorial Hospital School of Nursing (Laoag Ilocos Norte, 1903) Mary Chiles Hospital School of Nursing (Manila, 1911) The hospital was established by Dr. WN Lemon in a small house on Azcarraga, Sampaloc, Manila. In 1913, Miss Mary Chiles of Montana donated a large sum of money with which the preset building at

Gastambide was bought. The Tuason Annex was donated by Miss Esperanza Tuason, a Filipino Philantropist. 2. Frank Dunn Memorial Hospital (Vigan Ilocos Sur, 1912) 3. San Juan de Dios Hospital School of Nursing (Manila, 1913) In 1913, through the initaiative of Dr. Benito Valdez, the board of inspectors and the executive board of the hospital passed a resolution to open school of nursing. The school has been run by the Daughters of Charity since then. Sister Taciana Tinanes was the first Directress of the School Emmanuel Hospital School of Nursing (Capiz, 1913) In 1913, the American Baptist Foreign Mission Society sent Dr. PH Lerrigo to Capiz for the purpose of opening a hospital. Miss Rose Nicolet assisted him. The school offered a 3-year training course for an annual fee of Php 100.00. Miss Clara Pedrosa was the first principal Southern Islands Hospital School of Nursing (Cebu, 1918) The hospital was established in 1911 under the Bureau of Health. The school opened in 1918 with Anastacia Giron-Tupas as the orginizer. Miss Visitacion Perez was the first principal Other Schools of Nursing 1.Zamboanga General Hospital School of Nursing (1921) 2.Chinese General Hospital School of Nursing (1921) 3.Baguio General Hospital School of Nursing (1923) 4.Manila Sanitarium Hospital and School of Nursing (1930) 5.St. Paul School of Nursing in Iloilo City (1946) 6.North General Hospital and School of Nursing (1946) 7.Siliman University School of Nursing (1947) The FIRST Colleges of Nursing in the Philippines University of Santo Tomas-College of Nursing (1946) In its first year of existence, its enrolees were consisted of students from different school of nursing whose studied were interrupted by the war. In 1947, the Bureau of Private Schools permitted UST to grant the title Graduate Nurse to the 21 students who were of advance standing from 1948 up to the present. The college has offered excellent education leading to a baccalaureate degree. Sor Taciana Trinanes was its first directress. Presently, Associate Professor Glenda A. Vargas, RN, MAN serves as its Dean. Manila Central University-College of Nursing (1947) The MCU Hospital first offered BSN and Doctor of Medicine degrees in 1947 and served as the clinical field for practice. Miss Consuelo Gimeno was its first principal. Presently, Professor Lina A. Salarda, RN, MAN, EdD serves as its Dean. University of the Philippines Manila-College of Nursing (1948) The idea of opening the college began in a conference between Miss Julita Sotejo and UP President. In April 1948, the University Council approved the curriculum, and the Board of Regents recognized the profession as having an equal standing as Medicine, Engineering etc. Miss Julita Sotejo was its first dean. Presently, Professor Josefina A. Tuason, RN, MAN, DrPh is once more reappointed as the Dean of UP Manila College of Nursing The Philippine Board of Nursing is an administrative body under the Professional Regulation Commission that regulates the practice of nursing in the Philippines. Its three primary purpose is to: 1. Provide regulatory standards in the practice of Nursing by implementing the Nurse Practice Act and by lobbying to

Congress any proposed amendment to any laws with direct relationship to the practice of nursing. Ensure public safety by administering the Philippine Nursing Licensure Exam (PNLE) to graduates of nursing schools prior to practice of Registered Nursing in the Philippines. Maintain high standards of nursing education by auditing the performance of Philippine Nursing Schools.

Nursing comes to the Philippines Americans began training the first Filipino nursing students in 1907. Nursing students in the Philippines studied many of the same subjects as nursing students in the U.S. However, Choy says, the curriculum in the Philippines was never a mirror-image reproduction of the American nursing curriculum and involved more than a simple transfer of knowledge from American nurses to Filipino nurses. The first Filipino nursing students also studied subjects that were more relevant to their patients, such as the nursing of tropical diseases and industrial and living conditions in the islands, as described by Lavinia L. Docks 1912 book A History of Nursing: From the Earliest Times to the Present Day with Special Reference to the Work of the Past Thirty Years. In addition, Filipino nursing students studied English; today, the Philippines is the third-largest English-speaking country in the world. However, Choy notes, Filipino nursing students didnt lose their native language; Philippine schools of nursing believed the best way to promote physical health was to have a select few medical professionals spread their knowledge in the dialects of their own people, as described in the Philippine General Hospital School of Nursing Ninth Annual Announcement and Catalogue, 1915-1916. Through the 1930s, Philippine schools of nursing continued to adopt those aspects of American professional nursing they deemed relevant and appropriate, such as higher admission standards and the specialization of public health nursing. Training and practice at the hospital schools of nursing in Manila was violently disrupted when the Japanese occupied the Philippines in 1942, Choy says. However, U.S. colonial patterns in Philippine nursing education soon returned after the U.S. reclaimed the country in 1945 and even after the Philippines gained independence from the U.S. July 4, 1946.

Professional Practice: Nursing Law

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N urse Practice Acts (NPAs) are laws in each state that are instrumental in defining the scope of nursing practice. State boards of nursing oversee this statutory law. They have the responsibility and authority to protect the public by determining who is competent to practice nursing. Common Law is derived from principles or social mores rather than from rules and regulations. It consists of broad, interpretive principles based on reason, traditional justice and common sense. Together, the NPAs and Common Law define nursing practice. It is a nurse's responsibility to be informed on both the NPA and Common Law for the state(s) in which they are licensed to practice. It is critical for students and nurses need to be aware of the legal issues pertaining to the profession. Familiarity with the law and relevant court rulings helps in understanding the scope of practice and responsibilities that come with being a licensed caregiver, as well as providing insight on how to prevent legal problems before they happen. Read up on the NPA for your state - know your responsibilities and limitations. You may also want to subscribe to professional nursing journals to stay abreast of the latest court rulings. Here are a couple of case studies provided by Legal Eagle Eye Newsletter for the Nursing Profession, a monthly journal covering court cases, rulings and legislation pertaining to the nursing profession:

Healthcare Facility Liable for Student Nurse Error

T h e i m a g e c a

Nurses Negligent for Giving Nursing Functions to Aides

QUICK SUMMARY: A nursing student's negligence resulted in the fall and injury of patient during transfer. A nursing student at this students level had the training and should have been able to care for this patient. The student nurse testified she had received training to assist patients with ambulation and transfer. The nursing students preceptor testified the patient needed someone close with her at a safe distance at all times to ambulate. The healthcare facility was held to the same legal standard of care for a student nurses error or omission as for the same error or omission by a licensed professional nurse.

T h e i m a g e c a n n o t b e d i s p l a y e d . Y o u r c o m p u t e r m a y n o t h a v e e n o u g h m e m o r y t o o p e n

COURT OF APPEALS OF OHIO, 1996. The patients chart indicated that she had serious difficulty with her balance which made it necessary for her to have assistance when standing or walking with a walker and when transferring. She had fallen backward six days earlier, but was caught and lowered to the floor without being injured. She was afraid of falling and needed not only physical assistance, but also encouragement to take steps forward with her walker.

According to the Court of Appeals of Ohio, the student nurse had read the patients chart and knew the patient had weakness and an unsteady gait. Nonetheless, the student nurse helped her up from the commode, then walked away and left the patient standing with her walker in the bathroom, while the student nurse propped the door hinge open and adjusted her wheelchair, expecting the patient to walk to the wheelchair on her own to transfer with assistance. The patient took a step forward, fell backward and was injured.

t h e i m a g e , o r t h e i m a g e m a y h a v e b e e n c o r r u p t e d . R e s t a r t y o u r c o m p u t e r , a n d t h e n o p e n t h e f i l e a g a i n . I f t h e r e d x s t i l l a p p e a r s , y o u m a y h a v e t o d e l e t e t h e i m a g e a n d t h e n i n s e r t i t

The court ruled a healthcare facility will be held to the same legal standard of care for a student nurses error or omission as for the same error or omission by a licensed professional nurse. There was also testimony from a nursing instructor, that a nursing student at this students level should have known, the same as a graduate nurse, to stay close by this patient when standing or walking with a walker. Failing to give proper close attention to a patients need for assistance while ambulating is negligence, for which a healthcare facility can be held liable. Dimora vs. Cleveland Clinic Foundation, 683 N.E. 2d 1175 (Ohio App., 1996).

Emergency Room Assessment: Hospital Liable QUICK SUMMARY: The physician wanted his patient to Nurse's False Assurances that Infant Would Be receive skilled nursing care. He wrote an order for the home health nurses to re-pack her hip decubitus wound with antiseptic gauze. Instead, the nurses showed home health aides how to re-pack the wound and left QUICK SUMMARY: A nurse cannot stop their demanding them on their own to do wound care. Wound healing reassure parents their year, will the nurses without fully assessing the classified the baby a was delayed more than a infant and be all right were childs condition and obtaining a physicians classification scheme ruled negligent. examination. Based on the nurses reassurances, the require medical inter not have an immedia A home health clientparents did not wait to see the physician, and the child sued her home health agency died. The hospital was ordered to nurse told the paren because a hip decubitus wound site she sustained in pay nearly two million dollars for than it should be with them shortly the hospital took a year longer to heal negligence. have. Healing apparently was delayed by old gauze COURT OF there by a surgeon who The parents, howeve embedded in the wound, found APPEALS OF GEORGIA, 1996 The child had been heal and reassurances concern operated on the wound when it failed todischarged from the hospitals neonatal believed care unit health few minutes elected instead worsened. The judge intensive the home the day before his parents brought outer dressing, but they waiting for the child aides had been changing the him back to the emergency room. The parents told the emergency room triage nurse the baby had physician. The baby did not understand the rationale for sterile packing and re-packing of a deepturned blue at home,the original a bowel movement wound and had left had not had all entire time. The court faulted the gauze in the wound theday, appeared limp and that his eyes had rolled back in his head. The parents had been told to bring She did not take a co the child back the lawsuit by correctly assess the The nursing agency tried to defendto the hospital at once if the baby had even a slight aides how to was a change in his eating babys condition. The claiming its nurses had shown thefever, if there re-pack habits or if there was a change the physicians imme the wound with sterile gauze and replace the outer in his color. have. Most importan bandages, and had taught the patient how to do it From the court record in nursing effort to control and herself. The jury sided with the home health the Court of Appeals of Georgia, negligence. The patient, behaviors, had falsel agency and found no nursing it appeared that a struggle developed in the emergency had a reason for was all right and was however, insisted her physician room between the parents, who were highly agitated and insistent that their child be seen by attention. The court ordering skilled nursing care and insisted she was a physician The judge agreed with hospital on the nurse entitled to skilled nursing care. immediately, and the triage nurse on duty, who was intent awarding the hospital liable for pay her and threw out the jury's verdict,on insisting that the parents fill out certain from for the nurses action patient more than $100,000forms.the nursing agency. for leaving against m The Court of Appeals of Louisiana upheld the judge's South Fulton Medic decision to disregardAccordingandthe court, the triage nurse made a cursory the jury to award the patient examination of the baby. She then damages against the nursing agency notwithstanding repeatedly the jury's verdict. reassured the parents the baby was fine, apparently to calm the parents and A nurse testified as an expert witness for the patient that nurses do not have the option to change the physician's orders on their own. The court accepted the nurse as an expert on the nursing standard of care. The court ruled if the physician orders specific skilled nursing care, it means those specific nursing functions are to be performed by skilled nurses with their own hands, or by non-licensed persons with direct supervision by licensed professional nurses.
T h e i m a g e c a n n o t b e d i s p l a y e d . Y o u r c o m p u t e r m a y n o t h a v e e n o u g h m e m o r y t o o p e n t h e i m a g e , o r t h e i m a g e m a y h a v e b e e n

There was no documentation that licensed nurses ever performed the re-packing procedure or witnessed nonlicensed persons doing it. The aides signed off that they had performed wound care, but there was no documentation of what exactly they did. The judge interpreted it to mean they only changed the outer dressing, which would be wholly inappropriate care. Singleton vs. AAA Home Health, Inc., 772 So. 2d 346 (La. App., 2000).

c o r r u p t e d . R e s t a r t y o u r

c o m p u t e r , a n d t h e n o p e n

1. Contacts with _____________________________________________________________________ the Law o A nurse, most commonly, comes into contact with the law through possible or pending litigation as a About Legal Eagle Eye Newsletter for the Nursing Profession witness, according to Darlene and Keith TrandelLegal Eagle Eye Newsletter for the Nursing Profession was started in 1992 and has been published monthly ever Korenchuk since. Each month, the newsletter spotlights the latest U.S. court decisions and new Federal regulations affectingin "Nursing and the Law." Generally, this means hospitals, skilled nursing facilities, extended care nursing centers and home health agencies.The goal of the Legalthat the nurse was involved in or Eagle Eye Newsletter for the Nursing Profession is to reduce nurses fear of the law and litigation. By observed some action that gave rise to the legal highlighting action. However, if the nurse provided care to the the law that pertains directly to nursing, it gives nurses confidence to act appropriately. The editor and publisher of patient before or after the incident in question Legal Eagle Eye Newsletter for the Nursing Profession is nurse/attorney Kenneth Snyder. He has a Bachelor of took place, Science in Nursing from the University of Washington School of Nursing and a Juris Doctor from the University of it would be advisable for the nurse to contact Michigan School of Law. He is currently licensed as a Registered Nurse and as an Attorney at Law in Seattle, an attorney before proceeding with any discussion. The nurse also comes into contact with Washington. the law if a prohibited act is committed, such as negligence or malpractice. If this occurs, the nurse Legal Eagle Eye Newsletter for the Nursing Profession can be subject to criminal liability under a state http://www.nursinglaw.com criminal code, civil liability or licensing sanction. P.O. Box 4592, Seattle WA 98104-0592 Phone (206) 440-5860 Toll free fax 1-877-985-0977 e mail info@nursinglaw.com Indexed in Cumulative Index to Nursing & Allied Health LiteratureTM Responsibilities Nurse should be familiar with the Nurse Practice Act (NPA), which varies from state to state, as the individual state's regulatory board establishes its own version of NPA. Overall, the NPA defines a nurse's "scope of practice," which is determined by the title and formal education of the nurse. According to Trandel-Korenchuk, developments in nursing and legislation have expanded the scope, or limits of authority, of nursing practice. Moreover, the scope of the nurse's role in diagnosing, prescribing, and monitoring treatment is expected to continue to grown and expand. Therefore, it's up to the individual nurse to know and practice within the scope as defined by the regulatory board of the state of residence.

Nursing And The Law X JohnRoskoski This article was created by a professional writer and edited by experienced copy editors, both qualified members of the Demand Media Studios community. All articles go through an editorial process that includes subject matter guidelines, plagiarism review, factchecking, and other steps in an effort to provide reliable information. By JohnRoskoski, eHow Contributor updated September 23, 2010

Legal Protections Nursing practitioners, according to Medismart: Nursing Educational Resources, can protect themselves from most legal problems by following five basic guidelines: obtain an informed consent signature before treatment begins; document all actions regarding a patient's care; report any allegations of abuse toward a vulnerable population; protect the patient's right to privacy; and pay strict attention to avoid medication dosing errors.

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Professional Negligence Print this article Professional negligence, or professional malpractice, is the most common cause for legal action against health care professional in modern society, according to Nancy Brent in "Nurses and the Law." Nursing negligence occurs when the conduct of the nurse falls below a professional standard of "due care," which refers to the specialized knowledge of the nurse, on whom the public relies. When a nurse's conduct is alleged to be negligent, the nurse's conduct is compared to that of other ordinary, reasonable, and prudent professionals in the same or similar circumstances.

Liability According to Trandel-Korenchuk, establishment of liability depends on four conditions: duty, or what should have been done; breach of duty, or deviation from what should have been done; injury; and causation. If an incident does occur, the nurse or staff member should promptly notify the administrators responsible for risk management in the institution. In this way, steps can be taken to minimize the chance of a claim.

o
Nurses must balance patient care with legal concerns. Nursing, at all levels and in all areas of specialization, follows strict ethical guidelines and operates under governmental and regulatory statutes. All guidelines and statutes are generated by the concern for quality patient care. Often the interplay between ethics and law is complicated, but according to Kathleen Fenner in "Ethics and Law in Nursing," professional nursing ethics usually can be followed within legal boundaries and are likely to be legally defensible.

Read more: Nursing And The Law | eHow.com

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The book can be ordered from Springhouse publishers at 1(800) 666-5597 Although you cant order the book through Springhouses website, http://www.springnet.com it is very good website and provides a valuable source of information on many nursingrelated topics.

Nursing Law & Liability Catalano, chapter 8 At the end of this unit, you should be able to: 1. Discuss fundamental information on the laws that directly govern nursing, particularly the Nurse Practice Act. Understand how nursing law is applied in court. Describe the role of the state board of nursing. Define standards of care and discuss how these standards may be used as evidence during malpractice litigation. Discuss the legal significance of a nursing license

2. 3. 4.

Laws are rules to help protect people and keep society functioning. As a nurse, you must understand and accept the legal responsibilities of your practice. The courts expect the nurse to obey the laws the affect his/her practice. Ignorance of the law is not a valid defense in any legal case. Nurses must be familiar with their states nurse practice act and the role of the state board of nursing. They must also be familiar with the standards of care and how these standards may be used as evidence during malpractice litigation. Finally, nurses must know the significance of their nursing license and what to expect if disciplined for violating its provisions.

5.

As the 21st century begins, health care restructuring and the need for cutting health care costs are having a tremendous effect of how nurses care for patients. Profound changes in the legal and ethical dimensions of nursing practice have occurred. Enormous ethical and legal challenges face nurses today as they strive to provide high-quality care in a time of shrinking health care budgets. In times like these, nurses need accurate and up-to-date information on nursing law and ethics. Some of the challenges facing nurses today include:

Providing high quality care with less, as hospitals with declining operating budgets are forced to reduce nursing staffs. At the same time, nurses are responsible for managing larger patient loads than before.

Two major sources for laws in U.S. are STATUTORY & COMMON. Statutory Law

Shorter hospital stays for patients. Nurses must provide more care and more effective patient teaching in a shorter amount of time.

Statutory laws are: legislated laws enacted by Congress (FEDERAL STATUTES)

Many hospitals are replacing some RNs with lower-paid, unlicensed assistive personnel (UAPs). Nurses are held legally responsible for the care provided by these UAPs, thus heightening nurses liability.

state drafted laws (STATE STATUTES) laws drafted by cities (CITY ORDINANCES, CODES, REGULATIONS)

Courts of law continue to expand the definition of liability, holding nurses to higher standards. As nurses take on greater responsibility they become more accountable under the law.Even the most cnscientious and competent nurses have no guarantee that they wont be named in a malpractice lawsuit.

Common Law Different from statutory. Common law has evolved from decisions of previous legal cases that form a precedent. Common law extends beyond scope of statutory.

Patients are aggressive in asserting their rights and many do not hesitate to sue if they feel they have cause. Nurses must be constantly vigilant when using restraints, giving medications, obtaining information, witnessing informed consent, providing patient teaching, and performing all nursing tasks.

(e.g. no statues require negligent person who caused injury to another to compensate that person.) Court decisions have repeatedly ruled that the injured person be compensated. Common laws involve negligence or malpractice.

Nurses must act quickly and make crucial decisions during high-pressure patient care situations. All the while, the nurse must keep in mind the necessity of avoiding malpractice liability. *

*This information is adapted from an excellent book, Nurses Legal Handbook, 3rd edition. Springhouse: 1996. ISBN 0-87434849-8 I highly recommend that you purchase this book. It is an excellent and easy-to-use source of practical information on legal risks and ethical dilemmas in nursing.

Divisions of Law: Criminal & Civil Criminal Law Concerned with protecting society. Violations are punished at federal, state, county, and city level.

Two classifications of CRIMINAL LAW: 1. 2. Misdemeanor minor offense Felony major offense

4 Elements Required for Claim of Negligence: 1. 2. 3. 4. Duty was owed to client (professional relationship) Breach of Duty professional violated duty and failed to conform to standard of care Causality failure to act by professional was proximate cause of the resulting injury Damages actual injuries resulted from breach of duty

Nurses become involved under Criminal Law by 1. 2. 3. Civil Law Nurses are more often involved in violations of civil law than of criminal law. Most often involves nurses violation of individuals rights not renewing their license illegal diversion of drugs intentional or unintentional deaths

Examples of Nurse malpractice: failure to question Drs orders if not clear leaving objects in patient during surgery failing to assess failing to obtain informed consent

Terminology failing to report change in patients condition Plaintiff: one bringing dispute to court failing to do patient teaching Defendant: one accused of crime failing to report incompetence of a peer Answer: other side of the story failing to take action for patients safety Burden of proof: rests with plaintiff Criminal action: rendered when person is brought to trial and convicted Expert Witness: one who testifies in malpractice cases to help establish a standard of care Tort Law A tort is a wrongful act committed against a person or his property A tort is a violation of the civil law. Person committing the tort is a tort-feasor and is liable for damages Torts involve: violation of persons legal rights violation of a standard of care that causes and injury (eg: not putting the side rails up on a bed of a sedated or confused patient) "Professional negligence" is the same as malpractice. If nurse is found guilty: may have to compensate monetarily may have to pay medical expenses may have to pay out-of-pocket expenses may have to pay wages lost by patient may have to pay punitive damages (if acted in a willful manner)

Intentional Torts

Unintentional Torts

A willful act that violates another persons rights or property. Differs from malpractice in that the nurse must 1. 2. 3. intend to bring about the consequences of the act nurses act must be intended to interfere with the client or his property the act must be a substantial factor in bringing about the injury or consequences

Negligence is primary form of unintentional tort. Negligence is the commission or omission of an act that a reasonable and prudent person would do in a similar situation or would not have done. Medical Professional Liability (malpractice)

Common intentional torts are: Malpractice is a type of negligence for which professionals can be sued. Assault Because of their profession, nurses are held to a higher standard of conduct than lay persons. R.N. is charged with utilizing the degree and skill and judgment commensurate with his education, experience and position. (e.g. reasonable & prudent to put up side rails) Battery False imprisonment

Intentional infliction of emotional distress It is not necessary to prove that the injury occurred NOR is an expert witness required. May fall under criminal law if gross violation of standard of care.

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Publishing information that misrepresents the clients condition

y y y

Assault: threat or attempt to touch or do bodily harm to another person Battery: actual harmful or unwarranted contact with another person without his or her consent. (e.g. restraints or injection without consent) False imprisonment: occurs when a client is confined or restrained with intent to prevent him from leaving the hospital (e.g. restraints, detaining against his will, threats or medications) Intentional Infliction of Emotional Distress a common tort (e.g. mother who wanted to view her stillborn baby and was haded the baby in a gallon jug of formaldehyde)

Exception: child abuse or rape. Nurse is legally bound to report evidence of child abuse and would be acting appropriately if she/he gave information beyond the clients right to privacy. Rape must be reported to the police. 3. Breach of Confidentiality When a clients trust and confidence are violated by public revelation of confidential of privileged communication without the clients consent Privileged client information can be disclosed only upon authorization by the client Disclosure of information to family members is not acceptable unless authority is given by the client. Nurses who overhear privileged communication or information are held to the same standards as a physician with regard to that information.

Quasi-Intentional Tort

Facing a Lawsuit There is a higher probability now than ever before that a nurse will be involved in a malpractice action sometime in her career. Knowledge of the litigation process increases the nurses understanding of how his/her conduct might be evaluated before the courts. Statute of Limitations A malpractice suit against a nurse for negligence must be filed within a specified time.

Mixture of unintentional & intentional torts A voluntary act directly causing injury or distress without intent to injure or to cause distress. Usually involves situations of communication and often violate a persons reputation, personal privacy, or civil rights

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Defamation of Character

1-6 years is usual range with most common duration being 2 years. The Complaint Begins the litigation process

Most common of quasi-intentional torts harming a persons good name Injures a persons reputation Slander: spoken (eg: saying something about a person that is not true and that damages his/her reputation) Libel: written 2. Invasion of privacy

Describes the incident that initiated the claim of negligence against the nurse Specific allegations including the amount of money sought are stated. Plaintiff: usually a client or family member of a client alleged to be injured Defendant: person or entity being sued as nurse, physician, &/or hospital First notice of a lawsuit occurs when the defendant is officially notified or served with the complaint. Due process is the right of all defendants. The Answer Defendant must respond in writing to the allegations within a specific time frame This response is "the answer"

Violation of a persons right to protection against unreasonable and unwarranted interference with ones personal life To prove invasion has occurred, client must show: 1. 2. 3. 4. Nurse intruded on clients seclusion & privacy Intrusion is objectionable to a reasonable & prudent person Act intrudes on private or published facts or pictures of a private nature Public disclosure of private information was made

Examples of Invasion of Privacy 1. 2. 3. Use of clients name or picture for sole advantage of health care provider Intruding into the clients private affairs without permission Giving out private client information over the telephone If insured, the insurer will assign a lawyer to represent the defendant nurse The Discovery

Uncovering of all information relevant to the malpractice suit Interrogatories: a series of questions that the plaintiffs lawyer deems important Requests for production of documents (medical records, care plans, etc) The Deposition If false testimony is given, can be charged with perjury Formal legal process involving the taking of testimony under oath by court report (p 182) Deposition testimony is reduced to a written document called an "affadavit". The Trial May take place years after complaint is filed "Voire dire" process or jury selection Opening statements Plaintiffs side presented first Each witness or party subject to direct examination, cross examination, and re-direct examination Direct examination: open ended questions by the attorney ("tell me about") Cross examination: opposing lawyer asks questions to elicit short answers Closing comments Jury or judge for deliberaton

If the complication is named in the list of complications on the consent form, then client usually has no grounds to sue.

Good Samaritan Statutes Protect health care providers in emergency or disaster situations IF care is given according to established guidelines and within the scope of practice of that professional. Some limitations exist: Professional is protected only for those acts within that persons level of education. (eg a nurse could be sued if she performed surgery or did a trach on an accident victim. These actions would be beyond her scope of practice.)

Informed Consent Voluntary permission by a client to carry out a procedure on the client The person performing the procedure has the responsibility to obtain th einformed consent. Often, the physician gives the nurse the consent form and says "Get the client to sign this". Informed consent can be given only after the client receives sufficient information of the procedure, risks involved, outcome hoped for and consequences of not having treatment. The physician should provide most of this information. The nurse can reinforce the physician teaching, but should not be the only source of information for the informed consent. Exceptions to informed consent: 1. 2. In emergency situations when the client is unable to give consent In situations where the health provider feels that it may be medically contraindicated to disclose the risk and hazards because it may result in serious ill effects.

Delegation versus Supervision Decision or ruling made about the case can be appealed if either party is not satisfied. Possible Defenses to a Malpractice Suit Contributory Negligence Laws Clients are not allowed to receive money for injuries if they contributed to that injury in any manner. (e.g. if nurse forgets to raise the bedrail but instructs the client to turn on the call light, then client, in part, contributed to his own injury and cannot receive compensation) Comparative Negligence Laws The award is based on the determination of the percentage of fault of both parties. If the client is 50% or more at fault, no award will be made. Delegation: assigning or designating a competent individual the responsibility of carrying out a specific group of nursing tasks in the provision of care for certain clients. The person authorized to perform tasks is acting in the place of the RN and may be carrying out tasks that generally fall under the RNs scope of practice. Supervision: the initial direction and periodic evaluation of a person performing an assigned task to ensure that he or she is meeting the standards of care. Although delegation almost always requires supervision, it is possible to have supervision without delegation. When RNs delegate tasks, they are legally responsible for supervising that person to ensure that the care given meets the standards of care. Legally, the power to delegate is restricted to professionals who are licensed and governed by a statutory practice act. RNs are considered professionals and can delegate independent nursing functions to other personnel. LPNs/LVNs do not have delegatory authority.

Assumption of Risk If informed consent is signed, then the client is assumed to have been informed

Patient Self-Determination Act of 1990 Purpose was to encourage people to discuss and document their wishes concerning the type of treatment and care they want so it will ease the burden on their families and providers when it comes time to make a decision. Two Types of Advanced Directives 1. Living Will: States what health care a client will accept or refuse when client is no longer competent to make such decisions. Medical Durable Power of Attorney (Health care proxy): Designates another person to make health care decisions for a person if the client becomes incompetent or unable to make such decisions. Each state outlines its own requirements for executing and revoking the medical durable power of attorney and living wills. (e.g. Nancy Cruzan: U.S. Supreme Court stated that a living will would have been sufficient evidence of Nancys wishes to sustain or to remove her feeding tube. Burden of proof was put on Nancys family to show that she would not have wanted to continue living in this manner.)

Do not resuscitate orders must be followed regardless of the nurses personal values. Standards of Care Nurses are professionals and are therefore held to a higher standard of care. Standards of Care: the yardstick to measure the actions of a nurse involved in a malpractice suit. What action would be taken by a reasonable person who was placed in the same or similar situation. Nurses are judged against the standards that are established within the nurses profession and specialty area of practice. ANA as well as specialty groups within nursing publish standards of care. External Standards Guidelines developed by various nursing specialty practice groups Federal agency regulations Nursing standards developed by ANA, State Nurse Practice Act Criteria from accrediting agencies as the JCAHO Internal Standards Standards in specific hospital policy and procedure manuals that relate to the nurse in the particular institution (as job description) National criteria have replaced the locality rule standard. Nurses are held to both the local and the national standard. Standards are merely guidelines. In a negligence lawsuit, expert witnesses (persons who are experts in nursing) would be subpoenaed to testify and describe standards of care to the judge and/or jury. Nurses are held to these professional standards of care when they are on duty, no matter what. (tired, sick, understaffed, etc.) This is also true of nursing STUDENTS!! Students are accountable for any actions they perform. (students need malpractice insurance, too)

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The Nurses Role in Advance Directives Must know the laws of the state pertaining to advance directives and clients rights Must know the policies and procedures of the institution Not all clients can make decisions to formulate advance directives Discrimination must be prevented against clients and their families based on their decisions regarding their advance directives. Do Not Resuscitate (DNR) Orders Although DNR orders may be included in an advance directive, DNR orders are legally separate from advance directives. For the nurse to be legally protected, there must be a WRITTEN physicians order for a "no code" or DNR in the clients chart. The nurse must be familiar her his/her particular hospitals policy concerning DNR orders. The nurse must also know whether there is any law that regulates who should authorize a DNR order for a client who is unable to make this decision. Nurses may face legal dilemmas when dealing with confusing or conflicting DNR orders. (eg: it may be difficult to interpret a DNR order when it ahs been restricted, for instance, "do not resuscitate except for medications and defibrillation? or "no CPR or intubation") Lack of proper documentation in the medical records indicating how the DNR decision was reached can be an important and crucial issue if a medical malpractice case is involved and it is disputed whether or not the client or family actually gave consent for a DNR order. It is important that nurses not stigmatize patients who have DNR orders. (eg the practice of placing "dots" over the patients bed or on the wristband to identify a DNR patient) It would be extremely unprofessional to give "less than the best" care because "the client is going to die anyway". This abandonment can jeopardize care of the DNR client.

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Declaratory order A person who is enrolled or planning to enroll in an educational program that prepares the person for initial licensure as an R.N., and who has reason to believe that he/she may be ineligible for the license, may petition the board for a declaratory order as to the person's elibibility for a license. The board will investigate the petition and the person's eligibility for licensure. The most common cause for ineligibility is conviction of a crime. Law[4] is a system of rules and guidelines, usually enforced through a set of institutions.[5] It shapes politics, economics and society in numerous ways and serves as a social mediator of relations between people. Contract law regulates everything from buying a bus ticket to trading on derivatives markets. Property law defines rights and obligations related to the transfer and title of personal and real property. Trust law applies to assets held for investment and financial

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security, while tort law allows claims for compensation if a person's rights or property are harmed. If the harm is criminalised in a statute, criminal law offers means by which the state can prosecute the perpetrator. Constitutional law provides a framework for the creation of law, the protection of human rights and the election of political representatives. Administrative law is used to review the decisions of government agencies, while international law governs affairs between sovereign states in activities ranging from trade to environmental regulation or military action. Legal systems elaborate rights and responsibilities in a variety of ways. A general distinction can be made between civil law jurisdictions, which codify their laws, and common law systems, where judge made law is not consolidated. In some countries, religion informs the law. Law provides a rich source of scholarly inquiry, into legal history, philosophy, economic analysis or sociology. Law also raises important and complex issues concerning equality, fairness and justice. "In its majestic equality", said the author Anatole France in 1894, "the law forbids rich and poor alike to sleep under bridges, beg in the streets and steal loaves of bread."[6] In a typical democracy, the central institutions for interpreting and creating law are the three main branches of government, namely an impartial judiciary, a democratic legislature, and an accountable executive. To implement and enforce the law and provide services to the public, a government's bureaucracy, the military and police are vital. While all these organs of the state are creatures created and bound by law, an independent legal profession and a vibrant civil society inform and support their progress. Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death.

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Nurses work in a large variety of specialties where they work independently and as part of a team to assess, plan, implement and evaluate care. Nursing Science is a field of knowledge based on the contributions of nursing scientist through peer reviewed scholarly journals and evidencedbased practice.