Discussion Thread: Personal Application – Nursing and the Law
This week’s personal application assignment asks us to examine the legal and ethical issues of
our current area of practice. My personal experience in health care is in the area of long term
care, specifically assisted living and memory care for older adults. Deuteronomy 15:11reminds
us to provide support and love for those who are in need, “for there will never cease to be poor in
the land. Therefore I command you, you shall open wide your hand to your brother, to the needy
and to the poor, in your land” (English Standard Version, 2001).
There are endless examples in the Bible of God commanding Christians to care for the less
fortunate and these are the reason that I have chosen my specific area of practice. I am currently
the Executive Director of a 100 unit assisted living and memory care. In this role I am ultimately
responsible for all care and operations that occur in my setting. I oversee all departments of care
including the nursing department. For this discussion post I chose the chapter on nursing and the
law as it most closely relates to what I do each day. In the state that I reside, a license is required
in order to manage an assisted living setting. I am a Licensed Assisted Living Director and am
registered with the State of Minnesota Health Department. While I am in an administrative role
that is not directly involved in the nursing aspects of assisted living, I oversee the licensed and
unlicensed nurses and nursing assistants who provide direct care to the residents that we serve. A
Clinical Director, who is a Registered Nurse, oversees directly all nursing personnel and
operations.
Pozgar (2019) describes this role as a Nurse Manager and states that this role "has administrative
authority, responsibility, and accountability for the function, activities, and training of the
nursing staff" (p.266). In assisted living settings, most of the day to day care is provided by
unlicensed nursing assistants. There are Licensed Practical Nurses and Registered Nurses that
direct that day to day care and also oversee the general health of our residents. In my specific
role I interact directly with our organization's General Counsel and investigate and address all
legal issues that arise.
Legal Issues in Nursing and Long Term Care
One of the main legal issues for nursing in long term care is the delegation of services and tasks
from the nurse manager to unlicensed personnel and the oversight of these delegated tasks.
According to Pozgar (2019), a registered nurse who "knowingly fails to supervise an employee's
performance or assigns a task to an individual whom he or she knows, or should know, is not
competent to perform the task can be held personally liable if injury occurs" (p.266). In my
current role, I would be ultimately responsible for investigating any injury and hold the
responsibility for ensuring these things do not happen to protect my organization from action
under respondent superior (Pozgar, 2019, p.270).
Negligence is a risk in nursing throughout a resident's time in long term care settings. In assisted
living settings in Minnesota, medication administration is a delegated task. This means that
unlicensed but trained personnel are able to administer medications to patients under the
direction of a registered nurse.
The administration of medications requires nurses and nursing assistants to identify facility
residents correctly. Misidentifying residents when providing personal care services such as
dressing or grooming activities is not likely to result in injury. When administering medications
however the risk for injury if misidentifying a resident could be life threatening.
The monitoring and observation of residents in assisted living and memory care settings is a
common legal issue in nursing. According to Pozgar (2019), "nurses have the responsibility to
observe the condition of patients under their care and report any pertinent finding to the
attending physician" (p.274). In assisted living settings this can be more difficult as residents
have their own apartment homes and the interactions with facility staff are dependent upon their
service needs. My organization's policies and procedures outline the guidelines for reporting
changes of condition to resident's primary care providers. Nurses are expected to work within
their scope of practice and failing to report changes of condition based on facility policy opens
both the licensed nurse and the organization up to liability (Pozgar, 2019, p. 262).
A common legal issue for nursing in assisted living and memory care settings, in my experience,
is the failure to follow physician orders. Within the organization that I work we have taken steps,
through policy, to minimize the risk for incorrect orders to be applied to residents in our setting.
Our nursing team acts only on final written and signed physician orders as to ensure that verbal
orders or second hand relayed orders are not misunderstood by our nursing staff.
Ethical Issues in Nursing and Long Term Care
According to Pozgar (2019), nurses are not only caregivers but also take on the role of advocate
for patient care (p.289). Pozgar states that nurses, in hospital settings, have a duty to report
physician negligence and to question discharge if they deem that the patient may suffer further
harm without continued care. This concept is broadened to all settings in the current research on
the topic of nursing ethics. According to protecting patient rights is a main ethical issue for
nurses. Resident's in assisted living and memory care settings, in my experience, often have
designated representatives who provide them with support in decision making. Nurses in these
settings are required to both respect autonomy and act in the best interest of the resident.
Often the resident's desires for care conflict with both the concept of beneficence and the desires
of their designated representatives. It is a nurse's responsibility to partner with administration and
others in health care organizations to ensure that the resident is being provided with autonomy.
One area of ethical concern regarding nursing homes relates to resident privacy. A nursing home
is unlike a traditional home setting. The hospital-like environment of a nursing home can make
residents feel as though their autonomy has eroded. Typical complains among residents include
that they have lost control over everyday matters such as what they will wear, eat, and watch on
television. Such perceived loss of control or autonomy can contribute to depression and feelings
of helplessness. Further, residents might be asked to follow a schedule that is set for them by the
nursing home, which can upset their regular routine. This can make the adjustment for a new
nursing home resident rather difficult. Residents might also feel that they lack privacy if they are
required to share bedrooms, bathrooms, and common areas. Limitations on privacy can interfere
with the president’s ability to maintain control over life activities such as with whom they will
socialize and whether they will be sexually active.
Quality of care in nursing homes raises several ethical issues. There can be conflicts between
nursing home residents and staff members concerning what constitutes appropriate care. At
times, the nursing home staff might misperceive or misinterpret a resident’s desires. This can
occur if the decision-making capacity of a disabled elderly resident fluctuates, the staff’s
attempts to determine the resident’s wishes. Grief, confusion, and/or the use of certain
medications, for example, can temporarily interfere with a resident’s ability to make a decision.
Further, if the staff is not attentive enough to a resident’s condition, they might assume that the
resident is not capable of making decisions, when in fact the person is capable of doing so. A
resident might struggle with making a financial decision, for example, but maintain the ability to
make a decision about his/her health care.
The issues of neglect and abuse are important ones to raise when discussing nursing homes.
Nursing home residents tend to be a rather vulnerable population because of age, illness, and
finances. At times, residents have been taken advantage of, ignored, and abused by nursing home
staff. Further, there is concern that neglect and abuse might be underreported because residents
fear that their care will be detrimentally affected if they voice their complaints. Thus, the
monitoring of nursing homes is crucially important. Alternatively, there have also been cases
where residents have abused nursing home staff both physically and verbally. Depression, grief,
and confusion, for example, might cause a resident to mistreat a staff member.
Informed Consent
Informed consent can sometimes be an ethical battle for nurses. A dilemma can occur when there
is concern that patients and their families have not been informed or do not understand the
treatments used on a patient. There is a concern as sometimes patients do not feel comfortable
asking questions and giving consent without fully realizing the implications of their treatment. EE
If patients feel supported and trust their doctors and nurses, they are more likely to follow a
treatment plan and experience better outcomes. To avoid ethical dilemmas, nurses should ensure
that patients fully understand all the facets of their treatment plans. The details include knowing
all the risks and the layout of how a procedure will take place or how certain medications and
treatments will affect them. If they do not, this could jeopardize patient health and result in high
costs for the hospitals. Therefore, healthcare workers should take every measure to assure their
patients understand the treatment plan to obtain informed consent securely.
Protecting Patient Privacy and Confidentiality
Patient privacy and confidentiality are significant ethical issues faced by nurses. If not done
correctly, this can have legal ramifications and result in severe consequences for healthcare
professionals. With patients' medical information protected by the Health Insurance Portability
and Accountability Act (HIPA), there are definite boundaries and guidelines for protecting
patients' privacy.
Although nurses must protect their patient's rights and act in their best interest, they are still
obligated to respect patient autonomy. Patient autonomy, the right of patients to independently
make decisions about their care based on personal or cultural belief systems, is a prime principle
of nursing and should be respected by all healthcare professionals. With patient autonomy,
patients have the right to refuse medications, treatments, or procedures. Although this may
conflict with suggestions made by nurses and doctors, nurses will still have to respect this
decision and operate accordingly.
Shared Patient Decision-Making
Shared decision-making is a far more ethical approach to patient care than years ago when
healthcare professionals fully controlled patient treatment. Share patient decision-making
extends patient autonomy where patients and healthcare professionals work together to make the
best decision possible regarding patient care. With shared decision-making, patients and
healthcare professionals have open conversations about a patient's background, values, beliefs,
and culture, building a trusting relationship between patient and doctor.
Without a relationship, it will be extremely difficult for nurses and healthcare professionals to
get patients to communicate and cooperate properly. When patients are actively involved in
decision-making, they are more likely to be satisfied with their care and trust the doctor's
treatment plans. Healthcare professionals should be aware of the importance of educating their
patients even if the information shared with them is complex. If a patient fails to understand the
treatment, disputes among the patient and staff can occur.
Addressing Advanced Care Planning
Advanced care planning is always a difficult conversation for healthcare professionals to have,
predominately when end-of-life care conversations surround it. These conversations are between
patients and doctors when they need to make plans for their future health care if they pass away
or are left too ill to make their own decisions. Patients will explore, discuss, and document their
personal preferences regarding their healthcare. This process helps them identify their personal
goals and values about future medical treatment. They also will share who they would like to
make decisions on their health care if they can't make decisions for themselves.
Nurses tend to have the difficult task of ensuring these preferences are laid out and honored in a
medical emergency. For example, an issue might be if a patient has asked not to be on a
ventilator, but their immediate family demands. Despite the problematic scenario, nurses must
put the needs and wants of patients first, especially in end-of-life care.
Inadequate resources and staffing
Although this may not be an ethical issue put on individual nurses, healthcare executives
andEnurse managersEshould understand the lack of resources and inadequate staffing regarding
patient care. As healthcare costs continue to rise, nurse managers are at odds regarding budgeting
constraints and patient needs. When medical facilities have scarce resources, patients are at risk
of not receiving proper care—leaving nurses to make difficult decisions.
Hard decisions may also need to be made when facilities are faced with inadequate staffing
levels. When there is not enough staff for patients, nurses do not have the time to do everything
needed for each patient. Patient needs can include recovery times or even addressing the patient's
emotional and physical needs. A nurses' moral obligations to patients are compromised due to
work restraints and stress overload. They are left with mental struggles trying to decipher where
they should focus their priorities.
