PD HINDUJA COLLEGE OF NURSING

SEMINAR ON
“ASSERTIVENESS, VISIBILITY OF
NURSES AND LEGAL
CONSIDERATIONS”

Submitted to- Submitted by-

Mrs. Savita Raut Reshma S R
Lecturer 1st Year M.sc Nursing
PD Hinduja College of Nursing PD Hinduja College of Nursing

Date of submission: /05/2021

AIM AND OBJECTIVES
Aim: At the end of the seminar, the student will acquire knowledge regarding Assertiveness,
Visibility of nurses and Legal considerations and implement in nursing education and
practice.
Objectives: The student will:
 Define assertiveness
 Enumerate assertiveness and styles of communication
 Underline assertiveness in nursing
 Enlist factors influencing visibility of nurses
 Explain the current image of nursing and ways to improve visibility of nurses
 Narrate meaning and purposes of law
 Recognises importance of law in nursing

ASSERTIVENESS
INTRODUCTION
Assertiveness is a very essential skill required for our daily lives. We can get things done if
we are assertive. Of course, we must ensure that we are not aggressive. Whatever has to be
said has to state in clear and matter-of-fact terms and not in an abusive manner. Andrew
Salter, the hypnotherapist and early behavior therapist at London is credited with introducing
the term assertiveness, in 1949, to mean an inner resource to deal peacefully with
confrontations.
The term was reintroduced by Arnold Lazarus, Professor of Psychology who defined it as
“expressing personal rights and feelings, since its introduction it has become the major focus
in changing the stress related behaviours”. Assertive behaviour promotes equality in human
relationships, enabling us to act on our own interest, to stand up for ourselves without undue
anxiety, to express honest feelings comfortably, to exercise personal rights without denying
the rights of others

DEFINITION
Assertiveness is a form of behaviour characterized by a confident declaration or affirmation
of a statement without need of proof; this affirms the person's rights or point of view without
either aggressively threatening the rights of another (assuming a position of dominance) or
submissively permitting another to ignore or deny one's rights or point of view.

ASSERTIVENESS AND STYLES OF COMMUNICATION

-Passive communication
It is a style in which individuals have developed a pattern of avoiding expressing their
opinions or feelings, protecting their rights. Passive communication is usually born of low
self-esteem.
The impact of a pattern of passive communication is that these individuals:
 Often feel anxious because life seems out of their control.
Often feel depressed because they feel stuck and hopeless.
Often feel confused because they ignore their own feelings.

-Aggressive communication
It is a style in which individuals express their feelings and opinions and advocate for their
needs in a way that violates the rights of others. Thus, aggressive communicators are verbally
and/or physically abusive.
The impact of a pattern of aggressive communication is that these individuals:
 Become alienated from others.
 Generate fear and hatred in others.
 Always blame others instead of owning their issues, and thus are unable to mature.

-Assertive communication
It is a style in which individuals clearly state their opinions and feelings, and firmly advocate
for their rights and needs without violating the rights of others. Assertive communication is
born of high self-esteem.
The impact of a pattern of assertive communication is that these individuals:
 Feel connected to others.
 Feel in control of their lives.
 Create a respectful environment for others to grow and mature.

TEHNIQUES OF ASSERTIVENESS
Identify your personal rights, wants and needs.
Identify how you feel about particular situation.
Be direct: Deliver your message to the person for whom it is intended.
Own your message: In describing your feeling use ‘I’ statement to express your feeling
instead of evaluating or blaming others.
Avoid assumptions about others thinking or feeling or about how they may react.
Avoid statement that begins with ‘why’ and ‘you’.
Ask for feedback: It can encourage others to correct any misperception; you may have as
well as helps others to realize that you expressing an opinion, feeling of desire rather than a
demand.
Stop apologizing all the time
Learn to take compliment
 Act confident
 Feel free to say no, I don’t know and I don’t understand etc.
 Evaluate your expectations: Are they reasonable! Be willing to compromise.

ASSERTIVENESS IN NURSING
Assertiveness is defined as, “it is the quality of being self-assured and confident without
being aggressive.”

Aims of assertiveness in nursing

 Assertiveness is to find best possible solution for all people.
 Assertiveness increases the chance of nurse’s needs being met.
 Assertiveness is allowing nurses to remain in control.
 Assertiveness brings greater self confidence among nurses.
 Assertiveness reduces the stress among nurses.

Need for assertiveness in nursing

In all spheres of our professional lives, we have to be assertive. It is a competitive world
today. One faces many challenges in one’s work arena. Also, one has to deal with all kinds of
people. Some may be helpful and co-operative, and others may not be so helpful. It may not
be very easy to convince some people. At times your views may not be acceptable to the
other person. Only the person who is assertive can get his way or else everybody will trample
upon him or her. One has to be firm about things and not give easily to everything that
another person wants him or her to do.
 Assertiveness is an important issue in nursing practice.

 Education program in assertiveness knowledge and skills have been vague for some time
in nursing because nurses have recognized need for assertiveness in quality nursing care.
 Nursing hospitals involves negotiating complex interpersonal relationship and working in a
social and political context with in economic constraints, while balancing a multiplicity of
tasks and roles, nurses are busy clinicians who need to have a broad range of clinical
knowledge and skills and they are accountable to many people.
 Nurses has more on their minds than just helping patients every day they are confronted
with challenges such as communication issues and high stress levels.
 Nursing students will need assertiveness and it will be up to the individual to adjust his
behavior in order to obtain a job or promotion, to develop a carrier to increase her confidence.
 Maintaining diaries and role playing helps us to become more assertive. Use diaries to
track situations you have encountered where you did not behave assertively. Identify the
situation, describe in detail what happened and your level of anxiety during the encounter and
identify what you wish had happened.
 Use entries in your diary to role playing in your situations that cause your problems. You
can role play with your family and friends and alone. To make exercise effectively, you
should choose a situation you may have to deal with.
 As nurse works in different situations, they have to be assertive in order to meet the
challenges and to win the cooperation from others.

Need of assertiveness for nurses

Assertiveness is an important requisite for today’s professional nurse. As nurses move away
from traditional subservient roles and perceived stereotypes it is increasingly being
recognized that a nurse needs to be assertive. It mitigates against personal powerlessness and
results in personal empowerment. Nursing has determined that assertive behavior among its
practitioners is an invaluable component for successful professional practice. It enables us to
express ideas while respecting the ideas of others, overcome burnout and to reduce distress,
to solve problems diplomatically and tactfully, to negotiate healthily to tackle verbal abuse
and violence in work environment. Nursing is centred on the nurse-patient relationship.
Nursing is a profession whose “object” is the human being and thus the success of the work is
partly determined by the effective cooperation with patients and other health care
professionals.
Assertiveness is necessary for effective nurse/patient communication, and it is suggested that
its development may also aid the confidence of the profession as it develops. It is considered
as one of the essential life skills that must be developed by everyone.

Factors influencing assertiveness in nursing

Assertiveness is considered as an important responsibility of the nurses. And it is a learned
skill that has to be developed. There are different factors which influence the development
and practice of assertive behaviour in a person.
Two main factors that influence our decision to “speak up” or be assertive are
1. Our perception of the reaction of others to the situation Generally, in a group setting, if we
see something wrong, we first look at how others are reacting before we speak up. When we
look at the reaction of others, we are checking to see if they appear concerned with the
situation. If we find that others do not appear concerned, then we will probably be reluctant to
speak up.
2. Perceived obedience to authority. We may also not “speak up” because we believe we are
just following orders or that speaking up would represent questioning authority. This type of
obedience towards authority and the personal feeling of powerlessness inhibit the
assertiveness. Team leaders can reduce these barriers by ensuring that team members
understand that assertive behaviour is demanded of all personnel. Junior members must be
confident that senior leadership has empowered them to speak up, without fear of reprisal.
The factors influencing the assertiveness of a person can be broadly classified as:
 Extrinsic factors: Are factors lying outside the person.
 Intrinsic factors: Are factors within the person.

Extrinsic factors Intrinsic factors

Type of country Gender
Striving to keep up-to-date Marital status
Culture Genetics
Peer group Personality
Religion Self-esteem
Type of family Self confidence
Socio-economic status Attitude
Educational status Level of knowledge & Skill in practice
Profession and Role models Psychological factors-anxiety
Rearing pattern Style of coping with stress
Parent –child interaction
Mass media

-Universal changes
In some countries, the proper way of being assertive is important in creating relationships.
Project Globe (2003) studied the cultural differences in leadership, organizations, and society
over 60 countries. The study showed the level of assertiveness of the countries included in the
study as follows, the least assertive country was Sweden; the median assertive countries
consisted of Egypt, Ireland, Philippines, Ecuador, and France and the most assertive country
was Germany. In a professional atmosphere what some may see as assertive in America, may
see as aggressive in Asia. So, the way and style of behaviour of individuals highly depends
on the country in which they live, and the culture in which they are brought up.

-Culture
Culture determines the level of assertiveness to some extent. Assertiveness is seen as a
leadership quality in all types of cultures. Some cultures view being assertive as being
confident. There are important variations in interpersonal communication across cultures that
impact the “what” and “how” of being assertive. For example, traditional Asian cultures
value subtlety and indirectness in communication. More direct or confrontational styles may
be viewed as disrespectful and lacking in finesse. The traditional Indian culture also demands
high level of obedience from the students, ‘Guru’ is considered as god and the words of guru
has to be followed without any questions.
-Religion
Generally, it is seen that some religious rituals don’t promote the assertive behaviour from its
followers. They want people who blindly follow religious activities. The aggressive
behavioural style from these followers towards the persons of another religion results in
communal riots. On the other hand, Some religions may be supporting the passive style, for
example the Buddhist.

-Family income & other family factors

Family income is an important determining factor in predicting the assertive behaviour of the
person.

-Educational status
Education increases the awareness regarding the personal rights and the rights of others. So,
education promotes assertiveness. On the other end the individual may be either not
aware regarding their rights and remains as passive or behave aggressively considering the
self-rights alone.
-Profession
Professional autonomy determines the level of assertiveness of its members. Professionals’
having more independent and administrative function demonstrates high level of
assertiveness. Assertiveness increases with increase in professional experience also.
-Mass media
Variety of behavioural styles and reactions in the community are communicated through
mass Medias like radio, television, newspaper and the magazines. These reflect the
perceptions and opinions of the majority. Thus, helps in the formulation of behavioural styles.
Mass medias also influence the formation of personality this intern affects the assertive
behaviour of individuals.
-Parent –child interaction & rearing pattern
The interaction between the child and the parent for satisfaction of biological needs play a
significant role in the development of personality and behavioural style. It also helps in the
development of social dimensions of the child. It is from the parent the child learns the ways
for reacting to various situations and gets the confidence to react. The self-image of the child
is also formulated to some extent through parent child interaction. Some situations parents
may be accepted as the role models by the child. So, it is considered as an important factor
determining the assertive behaviour of an individual.
-Peer group
Peer group is the first group of individuals of the same/similar age may be unrelated
biologically but are related socially. Interacting with this group the child learns that he/she
should give up a little of individuality to be accepted socially in the peer group. With the peer
group, the child learns to take turns, to suppress his/her wish in favour of the decision of the
group, to dovetail his/her activities with the activities of the group. And with the desire to be
accepted, he/she moulds his/her behaviours to the standards set by the group which suggests
to him continually what would please the group members, in adolescence and even later
also this happens. The peer group persists as a factor of environment throughout life, of
course changing with time and maturity and helps in the development of individuality and
behavioural styles.

-Role models
Role models influence the behavioural style of the individuals. It can be parents, teachers,
famous personalities or the personalities observed through films or cartoons.
-Genetics
Basically, we inherit certain characters from the insisters, which include some physical
characteristics and some tendencies to function in certain ways. For example, the way we
react, predisposition to react slowly or fast ect. Thus, assertiveness is also influenced by the
hereditary factors.
-Gender
Gender is considered as factor predictive of assertiveness. It is reported that men are more
assertive than women. In the same vein, this finding is also contradicted with reports of
researchers like Chandler et al. who found that women were significantly more assertive than
men in some specific situations. Generally, it is said that the culture and the level of
education of the person determines the gender variation in assertive behaviour.
-Marital status
Culturally, the unmarried are mostly considered to be free and without restrictions. For
instance, the unmarried may make unilateral decisions on issues; the married may not be able
to do same. So, it is generally said that the unmarried is more assertive. But the literature
Search reveals that not much had been done with respect to marital status.
-Placement in the course
As the student moves from basic to advanced areas of the course the assertiveness increases.
Also attending various assertive training courses also help to increase the assertiveness.
-Personality
Personality is considered as an important factor that determines the assertive behaviour.
Neuroticism and extraversion and openness is said to be associated with assertive behaviour.
‘Type A personality’ usually having aggressive behaviour.
-Attitude
Attitude determines the behaviour of the person. Persons having positive attitude reacts
assertively.
-Psychological factors-anxiety & style of coping with stress
Anxiety is a barrier to assertive behaviour. If a person is anxious about the result of assertive
behaviour or what other people think if ‘I say NO’ won’t be able to behave in assertive
manner.
Literatures also reveal that there is negative correlation between anxiety and assertiveness.
-Self-esteem & self-confidence
Only a person having good self-esteem and self-confidence may be able to stand for him/ her.

BARRIERS TO ASSERTIVENESS
Mutual respect and restraint promote assertive behaviour. However, miscommunication,
misperception and other factors can create barriers. All must be aware of these potential
barriers and share the responsibility of eliminating them.
Barriers include, Lack of confidence in one’s own ability. Perception that someone is not
approachable; by his/her position, rank, of knowledge should already know what is
happening. Nurses are often considered to be lacking in assertive skills. An exploratory study
was conducted to compare the assertive behaviour of trained nurses at work and in general
life situations. Questionnaire and interview techniques are used to investigate the behaviour
of a small sample of staff nurses and enrolled nurses in general hospital settings. Trained
nurses are found to be less assertive at work than in general life situations. In the work
situation sisters are more assertive than staff nurses. The enrolled nurses are the least
assertive of the trained nurses. The complex nature of assertive behaviour becomes apparent.
Factors which promote assertiveness at work include knowledge, confidence, experience and
the wearing of uniform. Factors which inhibit this behaviour are tradition, training and the
hierarchical structure within the hospital. The use of assertiveness tends to be situation
specific. Assertiveness is viewed as a positive behaviour and is of value to nurses, but there
are mixed feelings about the usefulness of assertiveness training.

SUMMARY
Nursing is a profession, centered on the nurse-patient relationship. For the successful and
satisfactory work nurses require effective cooperation with patients and other health care
professionals. Assertiveness is necessary for effective nurse/patient communication, and it is
suggested that its development may also aid the confidence of the profession as it develops. It
is considered as one of the essential life skills that has to be developed by everyone. There are
different factors that determines the assertiveness behavior of the individual in general. This
review describes various factors influencing assertiveness in nursing.

CONCLUSION
Assertive behaviour helps individuals feel better about them. This increases self-esteem, job
satisfaction and ability to develop satisfying interpersonal relationships and there by
contributes to enhanced satisfaction in care recipients, be it the patient, family, community or
the students in school or college.
VISIBILITY OF NURSES
INTRODUCTION
Nursing is a dynamic profession undergoing change every moment “we are in a new place;
we are not on the edge of the old place. We are not pushing the envelope; we are totally a
new envelope. So, the rule has changed, ever fundamental premise old way of thinking is no
longer applies”- Sister Elizabeth Davis
Every time a nurse says to family, friends, or in public that he or she is a nurse, the nurse is
representing the profession. This has an impact on the image of nursing. Buresh and Gordon
stated, “We cannot expect outsiders to be the guardians of our visibility and access to public
media and health policy arenas. We must develop the skills of presenting ourselves in the
media and to the media—We have to take the responsibility for moving from silence to
voice”

Factors influencing Visibility of nurses

Students may wonder why it is so important for nurses to be more visible. They chose
nursing, so they know that it is an important profession. However, when they enter nursing,
many students also have a narrow view of the profession, much closer to what is portrayed in
the media—the nurse who cares for others with less understanding of the knowledge base
required and competency needed to meet the complex needs of patients.
What is the nurse’s voice? It is the “unique perspectives and contributions that nurses bring to
patient care”. Nurses have been silent about what they do and how they do it, but this has
been a choice that nurses have made—to be silent or to be more visible. External and internal
factors have impacted the nurse’s voice and this silence. The external factors are:
 Historical role of nurse as handmaiden (not an independent role)
 Hierarchical structure of healthcare organizations (has often limited the role of
nursing in decision making)
 Perceived authority and directives of physicians (has limited independent role of
nurses)
 Hospital policy (has often limited nursing actions)
 Threat of disciplinary or legal action or loss of job (might limit a nurse when he or she
needs to speak out—advocate)
Nurses who can deal with the internal factors can be more visible and less silent about
nursing. The internal factors to consider are:
 Role confusion
 Lack of professional confidence
 Timidity
 Fear
 Insecurity
 Sense of inferiority
This loss of professional pride and self-esteem can also lead to a more serious professional
problem. Nurses feel like victims and then act like victims. Victims do not take control, but
rather see others in control; they abdicate responsibility. It is much easier for nurses to feel
like victims, and this has also had an impact on nurses viewing physicians in a negative light,
emphasizing that physicians have done this to us. Consequently, nurses have problems saying
that they are colleagues with other healthcare professionals and acting like colleagues.
“Colleagueship involves entering into a collaborative relationship that is characterized by
mutual trust and response and an understanding of the perspective each partner contributes”
Each nurse has the responsibility and accountability to define himself or herself as a
colleague, and empowerment is part of this process
Visibility also has an impact on consumers and how they view nurses. As health care
changes nurses need to be actively involved in this process—in policy and funding decisions,
particularly any changes that impact nursing care but also broader healthcare issues. If nurses
are not viewed as vital members of the healthcare team and are seen only as team members
who hold a patient’s hand or serve as angels of mercy, they will not be more visible in the
critical process of change.

Current Image of Nursing and Impact by Past Images

“Although nurses comprise the majority of healthcare professionals, they are largely
invisible. Their competence, skill, knowledge, and judgment are— as the word ‘image’
suggests—only a reflection, not reality” .The public views of nursing and nurses are typically
based on personal experiences with nurses, which can lead to a narrow view of a nurse often
based only on a brief personal experience. This experience may not provide an accurate
picture of all that nurses can and do provide in the healthcare delivery process. In addition,
this view is influenced by the emotional response of a person to the situation and the
encounter with a nurse. But the truth is that most often, the nurse is invisible. Consumers may
not recognize that they are interacting with a nurse, or they may think someone is a nurse
who is not. When patients go to their doctor’s office, they interact with staff, and often these
patients think that they are interacting with a registered nurse (RN). When in the hospital,
patients interact with many staff members, and there is little to distinguish one from another,
so patients may refer to most staff as nurses.
This does not mean that the public does not value nurses—quite the contrary. When a
person tells another that he or she is a nurse, the typical response is positive. However, many
people do not know about the education required to become a nurse and to maintain current
knowledge, or about the great variety of educational entry points into nursing that all lead to
the RN qualification. There is less recognition of the other complex professional aspects of
nursing.

The role of nursing has experienced many changes, and many more will occur. It is the media
that is accused of representing nursing poorly, when, the media is reflecting the public image
of nursing. Nurses have not taken the lead in standing up and discussing their own image of
nursing—what it is and what it is not. It is not uncommon for a nurse to refuse to talk to the
press because the nurse feels no need to do this or sometimes because of the fear of reprisal
from the nurse’s employer. When nurses do speak to the press, often when being praised for
an action, they say, “Oh, I was just doing my job.” This statement undervalues the reality that
critical quick thinking on the part of nurses daily saves lives. Because of these types of
responses in the media, nursing is not directing the image, but rather accepting how nursing is
described by those outside the profession.
Gordon and Nelson commented that nursing needs to move “away from the ‘virtue script’
toward a knowledge-based identity”. For example, a video produced by the National Student
Nurses Association mentions knowledge but not many details, and instead it includes state-
ments such as, “[nursing is a] job where people will love you”. How helpful is this approach?
Is this view of being loved based on today’s nursing reality? Nursing practice involves highly
complex care; it can be stressful, demanding, and at times rewarding, but it is certainly not as
simple as “everyone will love you.” Why do nurses continue to describe themselves in this
way? “One reason nurse may rely so heavily on the virtue script is that many believe this is
their only legitimate source of status, respect, and self-esteem”. This, however, is a view that
perpetuates the victim mentality.
The connection of nursing with the angel image does not provide an accurate image of the
profession. There needs to be a more contemporary image of nursing to attract the next
generation of nurses. People have many career options today, and most want careers that are
intellectually stimulating. When nurses describe what they do, they frequently tell stories of
hand-holding and emotional experiences with patients, leaving out the knowledge-based care
that requires high levels of competency. At the same time, nurses are confronting heavy
pressure to demonstrate how nursing care impacts patient outcomes. However, it is difficult
to respond to this pressure if nurses themselves do not appreciate and articulate to others their
role and the knowledge and competency required to provide effective nursing care. Nurses
must remember that, in general, the public wants a competent nurse regardless of whether he
or she is warm and friendly.

Assessing Image and Increasing Visibility

-Advertising Nursing
The profession needs to understand why it is necessary to advertise nursing. Goals for any
initiative need to come from understanding the need, and goals for advertising nursing are no
different. There are a number of reasons for advertising nursing. First, of course, is the need
to attract more qualified people to nursing and to attract minorities and men to the profession.
Second, advertising has an impact on other groups that need to know about nursing—what
nurses do and the impact that nurses have on health care and outcomes. These groups include
policy makers, healthcare organizations, insurers, educators, school counsellors who may
direct students into nursing, and the consumer. Even when a school of nursing uses
advertising to recruit students, it also advertises about nursing in general to the public. This
makes the advertising complex. The preceding exemplar illustrates one complex,
multipronged campaign that has received positive and negative reviews.
-Men in nursing
Whilst there are low numbers of male nurses, there is no indication that they suffer in their
career. Pay disparity results in male nurses earning more than their female counterparts,
mainly from taking on more shifts and working overtime. Anecdotal evidence suggests that
male nurses are more likely to be fast-tracked into management positions.[17] Furthermore, a
report into the role of men in nursing found there to be more focus on human caring amongst
male nurses
-Minorities in nursing
Many organizations are working to help with nursing college tuition for students. Things like
scholarship programs and grants make it possible for more minority nursing students to go to
nursing colleges, become an RN or attend an RN-to-BSN program, and enter the workforce.

-The Role of Media

Today, the media is a powerful force. Through a great variety of media methods, people can
find information quickly; it is accessible anywhere, even on a cell phone. The media focuses
not only on news but also on related information in broad areas, including health care. The
media is interested in more than the news and weather. But if the media is to accurately
portray nursing as more than just caring, nurses must provide the information to inform the
public about nursing actions and activities and not be shy about taking credit when deserved.

 Media: Television, Radio, Film, Internet, Books, and Magazines

Healthcare issues can be found in all types of news and entertainment media (film and
television), and in other forms of media, including publications such as magazines and books.
How much is focused on nursing, and how is nursing portrayed? How can the profession
keep up with the media and know what the trends are? This is very important because the
profession needs information about the current media image(s) of nursing in order to
advocate for change if it is required.
 Use of Media by Nurses
There is a serious deficit in nurses’ presence in the media, and this problem continues today.
Journalists typically rely on physicians when they want statements about health care; most
would not even think of asking a nurse for an interview. Representatives of nursing
professional organizations, education administrators and faculty, and nurses who deliver
direct care are of particular interest to local news publications and broadcasts.
 Media Training
“The media is the primary means by which consumers and policy makers obtain information
about healthcare, about registered nurses, and about the nursing profession. While the
situation is gradually improving, RNs continue to be underrepresented in media coverage of
health issues—even where nurses are the primary experts”. Nurses need to pay attention to
positive images and note the type of image portrayed and whether it is an accurate image. For
example, a nurse may be portrayed as a caring individual in a television series, but there is
little (if any) emphasis on the nurse’s knowledge and competency, which is an inaccurate
portrayal of nursing. Nurses also need to consider whether nursing is left out when it should
be present in the media story.
Any nurse who becomes involved with the media needs to remember that he or she is an
expert and thus must demonstrate professionalism and expertise. Reminding oneself that the
public trusts nurses may help decrease anxiety when interacting with the media. Certainly,
preparing for an interview is important, and if the topic is known, one can consider what
types of questions might be asked. Keeping anger and defensiveness under control is
important. A thoughtful, clear answer is the best approach, one backed up by facts. If the
answer to a question is not known, the nurse should say so and then follow up with required
information. Many nursing organizations provide information and training for nurses who
may become involved with the media and are looking for nurses who want to do this type of
work for the profession. There three tiers or modes of communication that are important to
consider when educating the public about nursing:

1. Public communication through professional self-presentation

2. Public communication through anecdotal descriptions of nursing
3. Public communication through the mass media

-Collective bargaining
Collective bargaining is the process by which unions participate in administrative division
involving the terms of employment and the price of labor. Labor union tries to expand and
strengthen the position of the nurse as a large, potentially strong and powerful group of
professional people. Nurses must continue to foster a positive powerful image and continue to
organize.

-Computer technology
The visibility of nurses can be influenced by the increase in computer technology. The
development and implementation of computer technology enhances the management and
delivery of healthcare, and will continue to do so in the future. Documentation, care
planning, laboratory values, quality management and administrative records can be
computerized. Nurses save time by assessing a computerized system.to acquire the necessary
skill; nurses must become educated and proficient in computer technology.

-Elimination of external sexism

Sexism continues to harm and disrupt the professional visibility of nursing. Nursing is not
limited to one gender; nursing is genderless and its potential is equally as limitless. It is
suggested that increasing the number of male nurse will make the profession a different one.
The nursing profession and practice will also take on an improved public visibility of nurses
by having more balance between men and women.

-Development of internal media committee

Internal media, in the form of catalogs, brochures, newsletters, annual reports,
advertisements, films and educational materials are important to any health care institutions
relations but should be viewed as having equal importance to the image of nursing. It is
suggested that the health care facilities should have an internal media committee. Nurses
must become active in such committee and actively review all materials, paying special
attention to the effect these materials have on the visibility of nurse. Nurses must work with
the public relation committee to ensure that nursing is represented in a positive professional
manner to people.

-External media committee

The mass media, print and broadcast are the most pervasive influences on public attitudes and
opinions in contemporary life. Numerous nurses and group of nurses suggest that external
nursing media committees be organization. These media watch groups must take
responsibility for monitoring the media for all references to nursing. The groups must
respond to the media for positive and negative referrals to nursing

-Education
The visibility of nurses is changing due to the elevated efforts of our nursing leader to attain
the highest level of competency possible for our profession. The expectation for nursing
today call educated and motivated individual, so education strategies has become one of the
important strategies for improving visibility for nurses.

-Marketing
As the nursing profession works to upgrade its visibility, marketing strategies are important.
It is crucial that nursing services, nursing programs and the nursing profession be
strategically marketed to a wide range of audience to promote nursing excellence and to
project an achievement oriented, professional visibility of nursing.

-Visibility of nurse in cyberspace

"Healthcare professionals have been quick to ride the wave of the Internet revolution by
learning to use various kinds of internet tools that allow them to interact with each other,
unrestrained by national and geographical boundaries, time, and distance. They develop
collaborative research ideas and exchange information through the use of electronic mails,
subscribe to electronic newsgroups and participate in discussion lists".

-New forms of visibility of nursing

Nursing work is made visible by its own definition, measurements' and enumeration;
similarity, these are key elements in the governing process, as they allow for evaluation,
judgment and review. Initially, embryonic technologies produced nursing knowledge by
recording the type, number and outcomes of various patients (Winch 2001). These early
conceptions of nursing work has been extended and refined through medical record keeping,
and the production of quantitative and qualitative nursing research continuing until the
present. The evaluation of nursing work through evidence based reviews provides detailed
information that may enable governments to target and instruct nurses regarding their work.

-Initiatives That Impact Image

Influence is related to power—the power to cause others to agree to a certain direction.

Influence is tied to image. “Your identity as a nurse goes with you wherever you are whether
you are aware of it or not. How we present ourselves is an outward expression of our inner
experience. Our beliefs about ourselves color all that we do and say”. Influence is related to
how a person communicates with, and gains support from, others. Influence requires relation-
ships because it happens between people. A person can be influential in one area but not in
others. For example, a nurse with expertise in pediatric nursing may be able to influence
policy makers about a new policy related to child health but have no influence when it comes
to funding education for nurse anaesthetist programs.
1. Nurses must inform the public about nursing.
2. Every nurse must make public communication and education about nursing an integral
part of his or her nursing work.
3. Nurses must communicate in ways that highlight nurses’ knowledge rather than their
virtues.

-Nursing Initiatives to Address the Visibility of the Profession

The nursing profession has developed a number of initiatives to focus on the profession and
its needs— image, the nursing shortage, and the nursing faculty shortage. These issues are
interconnected. When developing these initiatives, the profession is standing up for change
and directing its own public image. The profession needs to take advantage of its strength in
numbers to influence health care and its own image.
 Nurses for a Healthier Tomorrow
Nurses for a Healthier Tomorrow (NHT) is a coalition of 42 nursing and healthcare
organizations that work together in developing a communications campaign to attract people
to the nursing profession (NHT, 2011). The goal of this campaign is to address the nursing
shortage from the standpoint of the faculty shortage. If there are not enough nursing faculty
members, schools of nursing cannot admit more students. NHT’s initial campaign was called
“Nursing. It’s Real. It’s Life.” Its focus was on attracting people to nursing. The 2004
campaign, “Nursing education … pass it on” included a series of ads to attract nurses to
nursing faculty positions.
 Raise the Voice Campaign
The American Academy of Nursing launched a campaign, Raise the Voice, to increase the
visibility of nursing . Academy president Linda Burns-Bolton, PhD, RN, challenged nursing
to begin to “call the circle,” in other words, to seek opportunities to participate in
interprofessional and corporate boards by first inviting others to meet with nursing leaders.
 Institute of Medicine Quality Series Reports
IOM report that focuses on nursing and the nurse’s work environment. The report emphasizes
the major role that nurses have in health care in any setting and that nurses spend more time
with patients than other healthcare professionals. No other report in this series focuses on one
healthcare professional group. Having nursing highlighted—and done so in a positive manner
that includes important recommendations for making the work environment more conducive
to effective nursing care—is a major step forward in clarifying the public image of nursing
and emphasizing that nurses have an important impact on patient outcomes.
 The Future of Nursing: Leading Change, Advancing Health
This IOM report (2011) strongly recommends that nurses assume more leadership roles in
healthcare delivery in all settings. The Institute of Medicine collaborated with the Robert
Wood Johnson Foundation to collect data through focus groups across the county and other
methods to determine how nursing can respond to a healthcare system that requires change.
“The report calls on nurses, individually and as a profession, to embrace changes needed to
promote health, prevent illness, and care for people in all settings across the lifespan”. This
report clearly elevates the image of nursing and recognizes that the profession has a major
role to play.

STRATEGIES THAT IMPACT IMAGE

Many strategies could be taken to improve the image of nursing. Several examples of these
strategies are described in this section, including those involving generational issues, power
and empowerment, assertiveness, advocacy, and the need for more men and minorities in
nursing.
-Generational Issues in Nursing: Impact on Image
Generational issues are important because the generations are part of the image of nursing.
When a person thinks of a nurse, what generation or age groups are considered? Most people
probably do not realize that there is not one age group, but several. Nurses in these four
generations are different from one another. What impact does this have on the image of
nursing? This means that the image of nursing is one of multiple age groups with different
historical backgrounds. How they each view nursing can be quite different, and their
educational backgrounds vary a great deal, from nurses who entered nursing through diploma
programs to nurses who entered through baccalaureate programs. Some of these nurses have
seen great changes in health care, and others see the current status as the way it always has
been. Technology, for example, is frequently taken for granted by some nurses while others
are overwhelmed with technological changes. Some nurses have seen great changes in the
roles of nurses, and other nurses now take the roles for granted—for example, the advanced
practice nurse. They believe that popular attitudes and assumptions about nurses and what
nurses contribute to a patient’s welfare can greatly influence the future of nursing. It is their
contention that since the 1970s, the popular image of the nurse not only has failed to reflect
changing professional conditions, but has been based on derogatory stereotypes that have
undermined public confidence in and respect for the professional nurse. Nurses should be
concerned about negative or incorrect images because such images can influence the attitudes
of patients, policy-makers, and politicians. Negative attitudes about nursing also may
discourage many capable prospective nurses, who will choose another career that offers
greater appeal in stature, status, and salary. This issue is of great concern today as
the shortage of nurses promises to become severe.
Current Generations in Nursing
■ ■Traditional generation Born 1930–1940
■Baby boomers Born 1941–1964
Generation X Born 1965–1980
Generation Y (also called millennials) Born 1981– present

-Television and Motion Pictures

The role of the physician was viewed as more important and physicians scored high on such
attributes as ambition, intelligence, rationality, aggression, self-confidence, and altruism.
When a nurse was the focus of a program, the story line involved the nurse’s personal
problems, rather than her role as a nurse. The nurse often was portrayed as the “handmaiden”
to the physician, and scored high on such attributes as obedience, permissiveness, conformity,
flexibility, and serenity. It is interesting to note that nurses ranked lower than physicians on
such items as humanism, self-sacrifice, duty, and family concern, all of which are values
traditionally ascribed to nurses.
-Play nurse
Nurses should be concerned about negative or incorrect images because these are
sure, to influence the attitudes of patients, policy makers, and politicians. nurses in the history
of film; nurses in film were lacking in such values as duty, self-sacrifice, achievement,
integrity, virtue, intelligence, rationality, and kindness. Few films centered on
the individual achievement or personal autonomy of the nurse. When compared with the
physician’s role, the nurse’s role was portrayed as less important. There is hope that this trend
is reversing. The film The English Patient, which received the Oscar as Best Picture of the
Year in 1997, added credibility to the role of the nurse by portraying the nurse character as
caring, thinking, and involved.

-Nurses in the Comics

Nurses have appeared in a number of comic books, mostly as romantic heroines. . Nellie the
Nurse began in the mid-forties, and The Romances of Nurse Helen Grant appeared in the late
fifties. A flurry of comics were devoted to nurses in the early sixties, including Nurse Betsy
Crane; Linda Carter, Student Nurse; Linda Lark; Cynthia Doyle, Nurse in Love; Sue and
Sally Smith, Flying Nurses; The Nurses; and Three Nurses. In the seventies, the dramatic
Night Nurse appeared briefly on the comic book racks. And, though she gained fame as a
reporter for the Daily Planet, the intrepid Lois Lane took time out from chasing Superman to
work as a volunteer nurse at Metropolis Hospital.

-The Image of the Nurse in Print

Novelists of the 1970s and 1980s often maligned their nurse characters, ignoring the nurses’
professional motivations and health care perspectives. Muff analyzed feminine myths and
stereotypes and has elaborated on nursing stereotypes. After reading books about nurses
written for school-aged, she drew the following conclusions:
 Nursing is described as glamorous.
 Medicine and nursing are imbued with a sense of mystery and elitism.
 Nursing is simplistic.
 Nurses move from job to job.
 Nurses are subservient and deferential, following orders, and running errands.

All of the nurses in these books were educated in hospital-based diploma programs, earning
the “RN” only after hours of hospital service, even though the Martin and Scott series were
both written in the 1960s.
In many instances, appearances (eg, the color and condition of the nurse’s hair) were most
important, and the nurse was portrayed as a “pure” girl, dressed in white, whose main aim
was to get a man, usually a doctor. Women who were not looking for husbands were in
nursing for altruistic reasons, and duty and self-sacrifice were glamorized. Muff also found
that the image of the nurse in the novel usually could be placed into one of the following
categories: ministering angels, handmaidens, battle-axes, fools, and whores. She stated that
the stereotypes of nursing presented in television and film also usually fit one of these
categories. When reviewing the nurse image on get-well cards, she had to add a new
category, that of “token torturer.” Only newspapers and newsmagazines tended toward
realism rather than fantasy. News articles examined the shortage of nurses, discussing reasons
for it (such as working conditions, salaries, benefits, and hardships). Special feature articles
also provided information about new or unique nursing roles, such as those of nurses in
Vietnam. Nurses serving in reserve status with branches of the military were among the first
called up when the conflict began. As our society recognizes the need to honor women as
well as men for their contributions, nurses are often singled out for special recognition—
especially during wartime. Suzanne Gordon, a journalist who is not a nurse became interested
in the profession and has written about nurses and nursing.

Although some might argue that nurses have better things to do than to worry about how
the nurse is portrayed in the media, a consistently misrepresented image can negatively affect
how the public views nurses. Therefore, nurses have responded to television advertisements
or programs that portray nurses and nursing in a negative light with letters and telephone
calls.
Various nursing organizations have waged campaigns to enhance the image of nursing by
emphasizing nursing as a prestigious, desirable, and respected career.
Following the Woodhull Study, the ANA initiated a program titled “RN = Real News,”
which was a media outreach program to showcase nurses as experts in the area of health care.
This initiative included a media speaker program and a media-training tool to help nurses
gain the basic skills and confidence necessary for dealing effectively with the media.

NURSING’S IMAGE AND THE NURSING SHORTAGE

Currently we are experiencing a serious nursing shortage that promises to become much
worse before it gets better.
The shortage is expected to reach serious. A number of factors are suggested as contributing
to the shortfall of registered nurses. First of all, nurses are getting older.
However, a factor that demands serious consideration relates to the fact that nursing has
always been a female-dominated profession. Women today have more educational and
occupational alternatives. Many other careers may seem more attractive than nursing in terms
of the salary commanded, the working conditions, and the prestige given to the role.
The shortage is of such import that various groups that command respect for their work
have decided to study the issue or take action to try to encourage more individuals to study
nursing. The Robert Wood Johnson Foundation funded a study with findings released in
2002. They recommended that a National Forum to Advance Nursing be created that would
draw together a wide range of individuals affected by the shortage. The Forum would focus
on helping nursing achieve higher standing as a profession. The Foundation has suggested
that the Forum would focus efforts in several strategic areas that include:
  Creating new nursing models to address the shortage, study nursing’s contribution to
health care outcomes and create new models of health care provision.
 Reinventing nursing education and work environments to address the needs and
values of and appeal to a younger generation of nurses.
 Establishing a national nursing workforce measurement-and-data collection system.
 Creating a clearing house of effective strategies to facilitate cultural change within the
profession.

Health care organizations in collaboration with state nurses associations have created similar
projects in local television markets. The sponsors of all these efforts hope that this will
result in increased enrolment in nursing programs.

Another factor affecting the nursing supply is the limited number of spaces in nursing
programs. Because nursing education is costly, most educational institutions have not
increased the size of their programs in the past decade. As applications increase, further
efforts will be needed to increase the number of individuals who can be admitted.
Scholarships have been made available in some areas to nurses who would consider faculty
positions.

Another aspect of the nursing shortage is the retention of current nurses. Some states
have identified that there are a large number of RNs not currently working in the profession.
Many experts have pointed to working conditions such as mandatory overtime, heavy
workloads, and lack of respect in the workplace as reasons for people leaving.

Nursing responsibilities for improving its own visibility

 Recognize that an image problem does exist and that each nurse has a responsibility to
improve the professions visibility.
 Strengthen involvement in professional organization, collectively, nursing is
extremely powerful.
 Provide all nurses including staff nurses to become salaried staff members rather than
hourly wage earners.
 Become politically active and politically knowledgeable, nurses should run for office.
 Document activities, it shifts the balance of power and allows nurses to state their
case on a rational basis.
 Demand that nurse authors be considered for editing health columns.
 Provide technical assistance to the media.
 Improve the community image volunteer for community sponsored activities.
 Revise and update nursing career literature, especially books in schools and public
libraries that introduce the profession to projective nurses.
 Establish school of nursing as research and information centers for people
experiencing, critical health care issues e.g. AIDS, homelessness. Be self-confident,
self-confident behavior commends respect.
 Share the positive aspects of the nursing profession with others.
 Learn to describe nursing responsibilities in clear, non-technical terms.
 Continue to develop alterative nursing education programs designed for adult nurses
needing to advance their education.
 Increase visibility makes service that client and their families know that nursing staff
is responsible for 24hour care.
SUMMARY
"Although nurses comprise most health care professionals, they are largely invisible. Their
competence, skill, knowledge is as a word image that suggest only a reflection, not reality".
(Sullivan E J 2004). The public of nursing and nurses are typically based on personal
experienced with the nurses which can lead to narrow view of nurses are often based on brief
personal experience. This experience may not provide an accurate picture of all that nurses
can do provide in the healthcare delivery system. The truth is that most often the nurse is
invisible. When in the hospital, the patients interact with many staff and there is little to
distinguish from one another, so the patient may refer to most staff as nurse. This does not
mean that people does not value nurses, they do. However, many people do not know about
the education required to become nurse or about the variety of educational entry points into
the nursing that lead to RN qualification. Nurses need to present themselves as profession
through all with whom they come in contact.

CONCLUSION
In short, the major responsibility for improving the visibility of nurses lies in the nursing
profession itself. Black and Germaine Warner suggested a variety of things nurses can do
including recognizing that each nurse should work to improve nursing's image, participating
in professional organization becoming politically active, writing for local media, providing
technical assistance to the media, taking advantage of public speaking opportunities and
sharing positive aspects of nursing with others.

LEGAL CONSIDERATIONS IN NURSING

INTRODUCTION
Safe nursing practice includes an understanding of the legal boundaries within which nurses
must function. As with all aspects of nursing today an understanding of the implications of
the law supports critical thinking on the nurse' s part. Nurses must understand the law to
protect themselves from liability and to protect their clients' rights.
Nurses need not fear the law be rather should view the information that follows as the
foundation for understanding what is expected by our society from professional nursing care
providers.

MEANING OF LAW
"Law is a rule or a body of rules of conduct inherent in human nature and essential to or
binding upon human society and to guide human functions".
" Law is the body of principles recognized and applied by the state and the administration of
justice".

PURPOSE OF LAW
 To define relationships among the members of a society and between individuals and
groups as they arise
 To define which activities are permitted and which are not.
  To allocate authority.
 To dispose of troubled cases as they arise.


TERMINOLOGIES RELATED TO LAW

Malpractice- Malpractice is defined as professional misconduct, unreasonable lack of skill
or fidelity in professional duties, evil practice, or illegal or immoral conduct.
Assault- Assault is any wilful attempt or threat to harm another, coupled with the ability to
actually harm the other person.
Battery- Battery is any intentional touching of another' s body or anything the person is
touching or holding without consent.
Contract- Contract is a written or oral agreement between two people in which goods or
services are exchanged.
Tort- Tort is a civil wrong for which remedy is common law action for liquidated damages
and which is not exclusively the breach of contract or breach of trust or other merely
equitable obligation.
Negligence -Negligence is the failure of an individual to do something that reasonably
prudent person would do or the commission of an act in particular circumstances in standard
of care to which a nurse is legally bound, would not do under similar circumstances.

Informed consent - Informed consent is a person' s agreement to allow something to happen

(such as surgery) based on a full disclosure of facts needed to make an intelligent decision
(i.e., knowledge of risks involved, benefits, alternatives, or consequences of refusal).

Crime- Crime is an offense against society that violates a law.

Felony- Felony is a crime of a serious nature that has a penalty of imprisonment for greater
than 1 year or even death.

Misdemeanour- Misdemeanour is a less serious crime that has a penalty of a fine or

imprisonment for less than 1 year.

Fidelity- Fidelity refers to the agreement to keep promises.

TYPES OF LAW

1)Public law- Public law governs the relationship between individual and the government
and governmental agencies.
2)Private law- Private law is the body of law deals with relationships among private
individuals.
3)Contract law- Contract law involves the enforcement of agreements among private
individuals or the payment of compensation for failure to fulfil the agreements.
4) Tort law- Tort law defines and enforces duties and rights among private individuals that
are based on contractual agreements.
SOURCES OF LAW

I. Constitutional law
Constitutional law deals with the relationship between the state and the individual and the
relationships between different branches of the state, such as executive, the legislative and the
judiciary.

II. Administrative law

Administrative law refers to the body of law which regulates bureaucratic managerial
procedures and defines the powers of administrative agencies.

III. Criminal law

Criminal law involves the state imposing sanctions for crimes committed by individuals so
that society can achieve justice and a peaceful social order.

IMPORTANCE OF LAW IN NURSING

 It provides patients against deliberate and inadvertent injury by a nurse.

 It protects the nurses against the suits if she renders right care.
 It provides a framework for establishing which nursing actions in the care of clients
are legal.
 It assists in maintaining a standard of nursing practice by making nurses accountable
under law.
 It differentiates the nurse's responsibilities from those of other health professional.

LEGAL LIMITS OF NURSING

1)Licensure

All registered nurses and licensed practical nurses are licensed by the board of nursing of the
state or province in which they practice. The requirements for licensure vary, but
requirements for education are in most licensing acts, and the nurse must pass an
examination. Licensure permits persons to offer special skills and knowledge to the public,
but it also provides legal guidelines for protection of the public. All states use the National
Council Licensure Examinations (NCLEX) for registered and licensed practical nurse
examinations.

A nurse's license can be suspended or revoked by the board of nursing if conduct violates
provisions of the licensing statue. For example, nurses who perform illegal acts such as
selling or taking controlled substances jeopardize their license status. Before licenses are
revoked, nurses must be notified of the charges and permitted to attend a hearing to present
evidence on their own behalf. These hearings are not court proceedings but are usually
conducted by the state or provincial board of nursing. Some states are provinces provide for
judicial review of such cases if the nurse has exhausted all other forms of appeal.
2)Standards of Care

One of the functions of law is to define the standards of care the nurse must provide. All U.S.
state legislatures and Canadian provincial parliaments have passed nursing practice acts that
define the scope of nursing practice.
Professional organizations are another source for defining the standards of care. The
American Nurses Association (ANA) and Canadian Nurses Association (CNA) have
developed standards for nursing practice, policy statements, and similar resolutions. These
standards are very general and include such recommendations as the obligation to provide
continuing education programs.

The written policies and procedures of the employing institution detail ways in which the
nurse is to perform duties. Such policies are usually quite specific and are set forth in
procedure manuals found in most nursing units. For example, a procedure and policy
outlining the steps that should be taken when changing a dressing or administering
medication gives specific information for nurses to perform these tasks. These policies
provide another definition of standards of care. Policies and procedures of institutions may be
more restrictive than nurse practice acts, but they can never request a nurse to act beyond the
standards of practice allowed by law.

3)Student Nurses

If clients suffer harm as a direct result of nursing students' actions, the liability for the
incorrect action is generally shared by the student, instructor, and hospital or health care
facility. Student nurses should never be assigned to tasks for which they are unprepared and
should be carefully supervised by instructors as they learn new procedures. Although student
nurses are not considered employees of the hospital, the institution has a responsibility to
monitor the acts of nursing students. Student nurses are expected to perform as a professional
nurse would; the law does not provide for a difference in quality of care rendered to clients .

Sometimes, student nurses are employed as nursing assistants or nurse' s aides when they are
not attending classes. If student nurses are so employed, they should not perform tasks that do
not appear in a job description for a nurse' s aide or assistant. For example, even if a student
has learned to administer intramuscular medications in class, this task may not be performed
by a nurse's aide.

4) Standing orders

Nurses are requested to execute prescribed orders. In case of emergency or the doctor/
medical personnel is not available, each nursing service area should have standing
instructions or orders for the nurses to carry out.

5)Informed Consent

Informed consent is a person' s agreement to allow something to happen (such as surgery)

based on a full disclosure of facts needed to make an intelligent decision (i.e., knowledge of
risks involved, benefits, alternatives, or consequences of refusal). The law has long
recognized that individuals have the right to be free from bodily intrusion.
The doctrine of informed consent not only requires that a person be given all relevant
information required to reach a decision regarding treatment, but also that the person be
capable of understanding the relevant information and does, in fact, give consent. One who
performs a procedure on a client without informed consent may be found civilly liable for
committing battery.

A signed consent form is required for all routine treatment, hazardous procedures such as
surgery, some treatment programs such as chemotherapy, and research involving clients. A
client signs general consent forms when admitted to the hospital or other health care facility.
Separate special consent forms must be signed by the client or a representative before
specialized procedures are performed. The following factors must be verified for consent to
be valid. These are the criteria for every type of tort, not only malpractice;

l. The person giving consent must be mentally and physically competent and be legally an
adult.

2.The consent must be given voluntarily. No forceful measures may be used to obtain it.
3.The person giving consent must thoroughly understand the procedure, its risks and benefits,
as well as alternative procedures.
4.The person giving consent has a right to have all questions answered satisfactorily.

5.If a client is deaf, illiterate, or has some other impediment of communication (such as
speaking a foreign language), an interpreter should be available to explain the terms of
consent.

6)Correct identity
All babies born in the hospital are correctly labelled at birth and to ensure that at no time they
are placed in the wrong cot or handled to the wrong mothers. All people in the hospital
should wear identity card. Every patient before being given premedication for any operation
should be labelled in the manner approved by the hospital.
7) Documentation
Keeping accurate and comprehensive records are essential in any health care facility. Records
provide a legal and business document. Regardless of the format used to record the data, it
should be accurate, concise and up to date. Verbal orders if carried out, then it should be
documented or written as "told over phone or verbal orders carried", etc. if a proper
documentation is done by for the activities done by the nurse, then she is safe in the hands of
law.

8)Drug maintenance
Checking the unlawful use of narcotic drugs is liable to drug dependence. These drugs should
be kept under lock and key.

LEGAL LIABILITY IN NURSING

When the nurse fails to meet the legal expectation of care, the client can initiate action if
harm or injury incurred by the client. These are mostly unintentional and intentional tort.

1) Unintentional tort
These types of tort are accidents that cause injury to another person or property.

Negligence and Malpractice are the examples of unintentional tort.

i)Negligence
Negligence is conduct that falls below the standard of care. It is established by law for the
protection of others against unreasonable risk of harm, and it is characterized chiefly by
inadvertence, thoughtlessness, or inattention.
If nurses give care that does not meet appropriate standards, they may be held liable for
negligence. Negligence may involve carelessness, such as failing to check a client' s arm band
and then administering the wrong drug. Another example of negligence may be administering
a medication even when it has been documented that the client has an allergy to that
medication. However, carelessness is not always the cause. If nurses attempt a procedure for
which they have not been trained and does it carefully but still harm the client, a claim of
negligence could be made.
Nurses have been involved in several common negligent acts including the following.

-Intravenous therapy errors resulting in infiltrations or phlebitis.

-Burns to clients
-Falls resulting in injury to clients.
-Failure to use aseptic technique where required.
-Errors in sponge, instrument, or needle counts in surgical cases.
-Failure to give a report, or to give an incomplete report, to an oncoming shift.

Nurses are responsible for performing all procedures correctly and for exercising professional
judgment as they carry out the orders of physicians and duties not ordered but for which they
have authority: And nurse who does not meet accepted standards of care while discharging
duties or who performs duties carelessly runs a risk of being found negligent.
ii)Malpractice

Malpractice is one type of negligence. It is defined as professional misconduct, unreasonable

lack of skill or fidelity in professional duties, evil practice, or illegal or immoral conduct. In a
malpractice lawsuit against a nurse, the following criteria must be established.
-The nurse (defendant) owned a duty to the client (plaintiff).
-The nurse did not carry out that duty.
-The client was injured
-The clients s injury was a result of the nurses failure to carry out his or her duty.
-These are the criteria for every type of tort, not only malpractice.
The best way for nurses to avoid being named in law suits is to follow standards of care, give
competent health care, document assessments, interventions and evaluations fully, and
develop empathetic rapport with the client. Poor client relations are leading causes of
lawsuits. A client who believes that the nurse performed duties correctly and was concerned
with his or her welfare is unlikely to initiate a lawsuit. In addition, careful, complete, and
objective documentation are keys to avoiding malpractice.
iii)Assault
Assault is any wilful attempt or threat to harm another, coupled with the ability to harm the
other person. The victim believes harm will come because of the threat. Assault may be
subtle; for example, a nurse might attempt to coerce a client into taking a drug he or she does
not wish to take. A more blatant example might involve a nurse handing an uncooperative
client in the emergency room. If the exasperated nurse yells.

"If you don' t take off those filthy clothes, I' m going to rip them off you!" and moves toward
the client, a claim of assault could be made.
2)Intentional tort
These types of torts are deliberate actions in which the intent is to cause injury to a person or
property these are more likely to be assessed against nurses and some intentional torts fall
under the criminal law, if there is gross violation of the standards of care. The following are
some of the intentional torts.
i)Battery

Battery is any intentional touching of another' s body or anything the person is touching or
holding without consent. Injury is not a requirement. There have been instances of battery of
confined clients by personnel in mental institutions. In a less drastic case, if a nurse attaches
foetal electrodes during labor without the consent of the mother, a claim of battery could be
made. The important issue is the client' s informed consent. In some situations consent is
implied. For example, if a nurse says, "I have your injection, Mr. Jones," and the client holds
out his arm, he is giving implied consent to the injection.
Whether the procedure that constitutes battery helps the client is unimportant. In a classic
case from 1905, Mohr V Williams, the client gave written consent for surgery on his right
ear. After the client was anesthetized, the physician discovered that the left ear was more
seriously affected, and he operated on the left ear. The client sued because surgery was
performed on the "wrong" ear.
ii)Invasion of Privacy
Clients have claims for invasion of privacy when their private affairs, with which the public
has no concern, have been publicized. A client is entitled to confidential health care. All
aspects of care should be free from unwanted publicity or exposure to public scrutiny. An
example of invasion of privacy occurs when clients are unnecessarily exposed in the room or
in the corridors.

Another form of invasion of privacy is the release of information to an unauthorized person

such as a member of the press or the client' s employer. Gossiping about a client' s activities
is another form of invasion of privacy and could lead to a charge of slander against the nurse.
Another example is a nurse s unwanted intrusion in private family matters. A nurse has no
right to intrude in matters not directly related to the client' s well-being. For example, a nurse
should respect a wish not to inform the client' s family of a terminal illness.

iii)Defamation of Character
Defamation of character is the holding up of a person to ridicule, scorn, or contempt within
the community. There are two types of defamation: slander and libel. For example, if a nurse
tells a client that his physician is incompetent; the nurse could be held liable for slander. If
the nurse writes such a comment, the charge would be libel. The important issues in a claim
of defamation of character are whether the information was shared with third persons (other
than the client) and if harm has been done to the reputation of the plaintiff.

LEGAL ISSUES IN NURSING

Legal issues in nursing practice reflect the changing trends in technology, medical
advancements and increased awareness among the patients.

i)Controlled substances
One of the legal issues that might arise for nurses involves the use of controlled substances.
The two acts that control the use of poison in medicine is: Misuse of drug act 1971 and
Dangerous Drug Act 1965 and 1967. The misuse of drug act aims at checking the unlawfully
use of the drugs liable to produce dependence or cause harm if misused. A drug affected by
this act is referred to as controlled drugs. The common controlled drugs under the dangerous
drug act involves cocaine, heroin, methadone, morphine, opium, pethidine, hallucinogens,
etc.

Controlled substances should be kept securely locked, and only authorized personnel should
have access to them. Criminal penalties for misuse of controlled substances exist. There have
been cases in which physicians have illegally prescribed and dispensed controlled substances,
and if nurses employed by such physicians fail to report these activities, they may be legally
accountable for aiding and abetting the physicians.
ii)Caring patient with AIDS
The care of AIDS and HIV+ patients has legal implications for nurses. Confidential
information must be protected of HIV + patients. An infected person cannot be discriminated
against based on contagiousness. The courts have upheld the employer's right to fire a nurse
who referred to care for an AIDS patient.
iii)Death and Dying
There are many issues regarding definition of death. The law identifies that death occur when
there is a greatly diminished brain function, despite function of other body organ. Even
though the client may be legally the brain death, the actual pronouncement of death is usually
the legal responsibility of the physician, nurses must be aware of legal definition of death.

iv)Autopsy and Organ donation

Legally competent persons are free to donate their bodies or organs for medical use.

Consent forms are available for the purpose. The nurse must be aware of the policies and
procedures of institutions and the laws in the state where they are asked to serve as a witness
for a person who wishes to give consent for a donation

v)Living Wills and Health care Surrogates

Living wills are documents instructing physician to hold or withdraw life —sustaining
procedures whose death is imminent. Each state providing for providing living will need two
witness, either of whom can be a relative or doctor are needed when the client sign the
documents, medical special directives also must be legally prepared with the appropriate
witness of the client's signature. Client executes these documents to appoint someone to make
health care decisions if and when they are no longer able to make decision on their own
behalf.

E.g. In terminally ill state and persistently vegetative state. Nurse should be aware of
institutional policies with the patient's self-determination act.
vi)Patient's property
Many of the unconscious patients admitted in emergency their belonging should be listed,
checked by two nurses and put in safe keeping. While a patient is in hospital, the nurse has no
right to go through his locker or personal property without his consent unless it is suspected
that the patient intent to injure him or others and has the means to do so. When the patient has
died in hospital, his possessions must be recorded in the property book, but money and
valuable should be listed and packed separately. Also write the color of ornaments and also
inform to administrative officers. Preoperatively and during delivery, these things should be
taken care of.

LEGAL CONCEPTS AND NURSING PRACTICE:

In addition to encountering legal problems in the care of clients, nurses may share liability for
errors made by physicians and other health care personnel or for inadequate care provided by
their employing institutions.
i)Physician Orders
The physician is responsible for directing the medical treatment of a client. The nurse is
obligated to follow the physician' s order unless he or she believes the order is in error or
would be determined to clients. Therefore, all orders must be assessed, and if one is
determined to be erroneous or harmful, further clarification from the physician is necessary.
If the physician confirms the order, but the nurse still believes it is inappropriate, the
supervising nurse is informed. A written memorandum to the supervisor detailing the events
in chronological order and the reasons for refusing to carry out the order should protect the
nurse from disciplinary action. The supervising nurse should help resolve the questionable
order. A nurse who carries out an inaccurate order may be legally responsible for harm
suffered by the client.

-The physician should write all orders, and the nurse should be sure they are transcribed
correctly. Verbal orders are not recommended because they leave possibilities for error. If a
-Verbal order is necessary as in an emergency, it should be written and signed by the
physician as soon as possible, usually within 24 hours.
-A difficult area regarding physician orders involves an order of "no code" or "do not
resuscitate" (DNR) for a terminally ill client. In the past many physicians were reluctant to
write such an order because they feared legal repercussions for "abandoning" a client. If a
physician has documented in his progress notes that the client' s condition is deteriorating and
that the decision not to administer cardiopulmonary resuscitation has been made, the
physician us perfectly justified in writing a no code order. Unless the physician decides that
such a discussion would be detrimental to the client' s condition, the order should be
discussed with the client. In such cases, the physician should also discuss the order with the
family. A no code order should be written, not given verbally.
Physicians should regularly review DNR orders in case the client' s condition warrants a
change. The nurse should be familiar with the institution' s policies and procedures
concerning DNR orders. Physicians can list all specifics of DNR orders. For example, a
physician may order vasopressors and fluid management to maintain a client' s blood
pressure. But also state DNR in the presence of cardiac standstill, lethal dysrhythmias, or
respiratory arrest.
ii)Short Staffing
During nursing shortages, the issue of inadequate staffing may arise.
The JCAHO has established guidelines for institutions to determine the level of staff needed.
These are referred to as staffing rations. Legal problems may arise if there are not enough
nurses to provide competent care. If assigned to care of more clients than is reasonable,
nurses should attempt to reject assignments by informing the nursing supervisor that they are
inappropriate. If nurses are required to accept the assignments, they should make written
protests to nursing administrators. Although these protests would not relieve nurses of
responsibility if clients suffered because of inattention, it would show that the nurse was
attempting to act in good faith. Nurses should not walk out when staffing is inadequate
because a charge of abandonment could be made.
Nurses are sometimes required to "float" from the area in which they normally practice to
other nursing units. In one case, a nurse in obstetrics was assigned to an emergency room. A
client emergency room and complained of chest pain. He was given a markedly increased
dosage of lidocaine by the obstetrical nurse and died after suffering cardiac arrest and
subsequent in-eversible brain damage. The nurse lost the malpractice lawsuit brought against
her.

Nurses who float should inform the supervisor of any lack of experience in caring for the
types of clients on the new nursing unit. They should also request and be given orientation to
the unit. Nurses floated to a unit are held to the same standards of care as nurses who
regularly work in that area.
iii)Incident

An incident report is filed when something arises that could or did cause injury and that was
not consistent with good care. For example, if a nurse administers an incorrect dose of
medication, a client falls out of bed, or an intravenous solution infiltrates the skin causing
sloughing and scar formation, the nurse should complete an incident report. Most institutions
provide specific forms for this purpose. The nurse objectively records the details of the
incident, and the physician examines the client and reports any untoward effects caused by
the error. Subjective assumptions should not be included on the incident report nor should
statements assigning blame be included.

iv)Reporting Obligations
Nurses are required to make a report in such situations as child abuse, rape, gunshot wounds,
attempted suicide, or certain communicable diseases to the appropriate authorities. The nurse
may also be required to report unsafe or impaired professionals. Because information that
must be reported varies among states and provinces, the nurse should become familiar with
the appropriate statutes.
v)Good Samaritan Laws
Good Samaritan Laws have been enacted in almost every state and province to encourage
health care professionals to assist in emergency situations. These laws limit liability and offer
legal immunity for people who help in an emergency, providing they give the best possible
care under the conditions. If a nurse stops at the scene of an automobile accident and gives
appropriate emergency care such as using caution when moving the injured person in case of
a spinal injury or applying pressure to stop haemorrhage, the nurse is acting within accepted
standards, even though proper equipment was not available.
vi)Contracts

A contract is a written or oral agreement between two people in which goods or services are
exchanged. An oral contract is as legally binding as a written one, but it may be more
difficult to prove. A breach of contract occurs if either party fails to carry out agreed
obligations.
By accepting a job, a nurse enters into an agreement with an employer. The nurse will
perform professional duties competently, adhering to the policies and procedures of the
institution. In return the employer not only pays for services but also furnishes the facilities
and equipment in proper working order to enable the nurse to provide efficient and competent
care.

Nurses also enter into contractual agreements with clients. Nurses agree to give competent
care, and clients agree to pay for the services. When clients sign admission forms upon
entering the hospital or agree to nursing care in any health care agency; they initiated the
contract. Private duty nurses have specific written contracts with their clients. It is from such
contracts that the duty to perform competently arises and the failure to follow through leads
to the concept of negligence.

LEGAL RESPONSIBILITIES OF NURSE

 Responsibility of appointing and assigning
Nursing administrators are expected to be aware of legal restrictions affecting personnel
appointment and assignment. The nurse administrators have the responsibility for staffing and
supervising nursing units to ensure safe effective patient care. Each nurse have the legal
responsibility to make full disclosure of her or his background knowledge and skills and
notify the nurse manager who given an assignment for which he or she is not qualified.
 Responsibility in quality control
The nursing administrator and the authority of the agency at all levels have the legal
obligation to ensure nursing care quality. A nurse manager's legal responsibility for quality
control of nursing service imposes a duty to observe report and correct the incompetence of
any patient care provider.
 Responsibility for equipment
To protect patients and employees from injury a nurse manger must ensure that all patient
care equipment is fully functional, and that the defective equipment is promptly repaired or
replaced. Nurses have the duty to refuse the equipment if it is faulty.
 Responsibility for observation and reporting
Nursing personnel have more frequent and prolonged patient contact than other care giver.
Nurses are trained to detect significant symptoms and reactions. Nurses have a legal duty to
observe patients frequently and report findings. The nurse is expected to observe a patient
more closely when his or her condition implies increased health risk.

The nurse has a duty to record and report observations of a patient condition promptly, so that
the physician can base treatment, decisions on up to date information about the patient health
care needs.
 Responsibility to protect public
The nurse has a legal duty to protect the public from injury by dangerous patients. Each nurse
manager or administrator should ensure that the agency in which she or he is employed has a
policy describing the procedure to be followed when a patient with violent tendencies or who
threatens violence to others is discharges or escapes from the health care agency.
  Responsibility for record keeping and reporting
Nurses have legal; responsibility for accurately reporting and recording patient's conditions,
treatment, and responses to care. The medical record is a written or computerized account of
a patient’s illness and treatment that includes the information submitted by all members of
health care tea. The medical record is an information source document should be used to plan
care, evaluate care, allocate cost, educate personnel etc.
 Responsibility for death and dying
Nurses must be aware of legal definition of death because they must document all events that
when the patient is in care. Sometimes there will be issues of euthanasia either active or
passive.

LEGAL ISSUES IN SPECIALTY PRACTICE AREAS

MATERNAL AND INFANT NURSING
Many legal issues are involved in the care of mother and her infant. Alike against a doctor
who is in charge of looking after mother and infant might be one of the following;
 Failure to diagnose a high-risk pregnancy
 Delay in performing a caesarean section
 Improper vaginal delivery or failure to perform a caesarean section
 Improper use of forceps
 Incidence surrounding inducting labor and use of Oxytocin
 Delay in arriving at the hospital
 Nonattendance at the delivery
The common causes for lawsuits against nurses will include the following;
 Problems of medication
 Failure inadequate client monitoring
 Failure to adequately assess the client
 Failure to report changes in the patient
 Abortions
 Nursing care of new born
PEDIATRIC NURSING
As in all areas of nursing practice, negligence involving pediatric clients is possible. Pediatric
nurses are responsible for preventing children, and their care, from accidently harming
themselves.

MEDICAL SURGICAL NURSING

As in the case of pediatric clients, disoriented adults may require some form of restraints.

Some common acts of negligence in medical surgical nursing are as follows;

  Overlooked sponges, instruments needles: in the operation theatre it is a responsibility
of the nurse to count the sponges, instruments, needles before the closure of the
abdomen or any cavity.
 Burns: the professional nurse is requires knowing the cause and effect of any heat
application so as to avoid burns. The nurse could be held liable if she/he neglects to
take proper safety measure prior to application of such measures.
 Falls: the nurse could be held liable if a patient falls from the bed due to improper
securing of patient on examination table or improper application of restraint or
provision of a proper bed for an unconscious patient or a child.
 Injury due to the administration of wrong medicine, wrong dosage and wrong
concentration: administration of medicine without prescription by any concerned
authority, mixing up of poisonous and non-poisonous drug in cupboards, leading to
errors, and failing to identify right medication for right patient in right dosage, at right
time considered as negligent act can be liable to be used.
 Loss or damage: the nurse is held liable ifa patient's property is lost when it has been
entrusted to her/ his care.
 Assault and battery: failure to take the informed consent of the patient prior to any
procedure, treatment, investigation or operation the nurse is held liable.
 Failure to report accidents: the nurse has a moral and legal responsibility to report to
the concerned authority any accidents, losses or unusual occurrences. Failure to do
this is an act of negligence.
 Maintenance of records and reports: failure to maintain accurate record and reports or
removing a position of record may also make the nurse liable.
 Nurses working in critical care units are also legally accountable for performing their
duties. Critical care nurses require additional training and ongoing intensive education
to provide them with information. The possible problem occurs in critical care nurses
is associated with the use of electronic monitoring device.
PSYCHIATRIC NURSING
The practice of psychiatric nursing is associated and influenced by the right of patients and
quality of care they are receiving.
In psychiatric setting the process of hospitalization can be traumatic or supportive for the
individual depending on the institution, attitude of the family and friends. At present three
types of admission are being used that is voluntary and involuntary.
 Informal admission
This type of admission to the psychiatric hospital occurs in the same way as a person is
admitted to a general medical hospital without formal or written application
 Voluntary admission
Under this procedure any citizen of lawful age any apply in writing admission to a public or
private psychiatric hospital. This is preferred type of admission because it is like that of any
medical hospitalization. When admitted as voluntary the patient remains all civil rights
 Involuntary admission
Involuntary commitments are continuously recognized by the court based on two theories;
first under its police power the state has the authority to protect the community from the
dangerous acts of the mentally ill.
Most laws justify commitments of the mentally ill on these grounds;
 Dangerous to others
 Dangerous to self
 Need for treatment
State laws on commitment vary, but they attempt to protect the individual who is not
mentally ill from being detained in the psychiatric hospital against his will, for political,
economic family or other non-medical reason. Action is begun with sworn petition by a
relative, friend, public official, physician or any interested citizen stating the person is
mentally ill and as in need of treatment. Some states allow only specific individuals to file
such petition.
The decision as to whether the patient requires hospitalization is then made. Precisely who
makes this decision determines the nature of the commitment.

LEGAL ROLES OF NURSES

Nurse as provider of services, if any malpractice claims are filed under the law of negligent
tort, and should prove the following:
 A legal duty of care existed.
 The nurse performed the duty negligently.
 Damage was suffered by the plaintiff as a result.
 The damage was substantial.
 Provide standard nursing care.
 Know the laws.
 Keep record and reports.
 Consult a lawyer if any question arises.
 Nurse as an employee, accurate supervision and evaluation of her responsibility.
 Nurse as a citizen
Community health nursing is the combination of nursing practice and public health practice.
Two legal aspects apply to most practice situation, such as;

 Professional negligence or malpractice

 Scope of practice
 Examining the usual and customary practice of profession.
 Considering how legislation defines the practice of profession in a jurisdiction.

MEDICO LEGAL ASPECTS OF DEATH

 Be with the patient during death.
 Reassure the patient relatives.
  Do not whisper in the patient and relative’s presence.
 Death declaration should be the responsibility of the doctor.
 Proper recording of the death should be done in the hospital record.
 Respect the body and conduct all the last offices of mummification of the body. Body
should be kept for observation for at least 3 hours to prevent misconception in case of
cadaver spasm.
 Take signature of the party, before handing over the body in death register and case
paper.
 In case of unknown patient, intimate nursing superintends and sent to mortuary with
proper labelling.
 In the case of MLC intimate the police.

SUMMARY
The analysis of the results has brought to fore, a large number of issues that need to be
addressed in view of the rapidly changing canvas of modern nursing in India. The increasing
role of a nurse as a patient care- taker and advocate, on one hand and her requirement of
having in depth knowledge of the legality of her actions on the other hand, have raised the bar
of nursing. The changes in the health status of a patient can be gradual or sudden and nurses
are usually the first to see the changes and to take action. A nurse’s accuracy in assessing,
monitoring and reporting of changes in health status in time, to a physician, can often spell
the difference between life and death.

CONCLUSION

The nurse in the modern era has multifunction in their work setting. In spite of having in the
job description, these job activities are not explicitly defined. There is job ambiguity , so in
that situation they need to know about the law and legal issues that can have positive impact
on them in day to day functioning and on their clients who are the recipient of their care
nursing practice is governed by many legal concepts. It is important to know the basics of
legal concepts because nurse is accountable for their professional judgments and actions.

RESEARCH ARTICLE-1

RESEARCH ARTICLE-2
CONCLUSION

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