Legal and Ethical Issues in Community Health Nursing

This chapter contains-

• Definitions, Sources of Law• Types of Law, Legal Concepts of Crime/Torts
Grossly Unethical Behavior in Community Area,
Professional and Legal Regulation of Nursing Practice, Nursing Standards (ANA)
Ethical Issues need to be considered in Community Interventions,
General Ethical Responsibilities, Importance of Ethical Behavior in Community Interventions.
The community health nurse experiences many ethical conflicts in health care delivery system.
Especially she must be very careful while doing services in the community because; there is a
team of people working in the hospital but in community she works alone. Therefore, she must
be more careful and she should have enough knowledge on legal issues.

DEFINITIONS

Law: Body of rules to guide human action. It is a standard or rules of conduct established and
enforced by the government. These are intended to protect the public.

Ethics: Ethics is a system of moral principles, and rules of conduct recognized in respect to a
particular class of human actions or to a particular group of people. In other way ethics is a code
of thinking and behavior

Governed by a combination of personal moral, legal, and social standards of what is right.

Sources of Law

Constitution: It is a system of fundamental laws or principles that govern a nation or society. It

defines the structure, power and limits of government and it guarantees citizens some
fundamental rights. Constitution gives the authority to the other sources of law. It has less direct
effect in malpractice.

Statutory or legislative law: Laws pad by the local, state or federal legislative body.

*Administrative agencies: The rules regulations established by executive brand of the

regulations that enforce statutory law

Tort law or court decision: Judicial and decisional laws are made by the court to interpret legal
issues are known as tort law.

Types of Law
Criminal law: Criminal law is the body of law that relates to crime. It regulates social conduct
and prescribes whatever is threatening, harmful, or otherwise endangering to the property, health,
safety, and moral welfare of people. It includes the punishment of people who violate these laws.

Civil law: A body of rules that delineate private rights and remedies, and govern disputes
between individuals in such areas as contracts, property, and family law: distinct from criminal
or public law.

Administrative law: Administrative law is the body of law that governs the activities of
administrative agencies of government. Government agency action can include rule making,
adjudication, or the enforcement of a specific regulatory agenda.

Legal Concepts of Crime/Torts

Crime/torts refer a wrong committed by a person against another person or his/her property.

• Crime: Crime denotes an unlawful act punishable by a state.

Misdemeanor: A criminal offense that is less serious than a felony and more serious than an
infraction is generally punishable by a fine or incarceration in a local jail, or both.

Felony: The term felony means a serious crime. The word originates from English common law,
where felonies were originally crimes that involved confiscation of a convicted person's land and
goods. Other crimes were called misdemeanors

Infraction: A violation or infringement of a law or agreement.

Litigation: An action brought in court to enforce a particular right. The act or process of
bringing a lawsuit in and of itself; a judicial contest; any dispute.

Plaintiff: It is also known as a claimant or complainant, is the term used in some jurisdictions for
the party who initiates a lawsuit/action before a court.

Defendants: A defendant is a person or entity accused of a crime in criminal action or a person

or entity against whom some type of civil relief is being pursued in a civil case. Terminology
varies from one jurisdiction to another.

Tort: It is a civil wrong that unfairly causes someone else to suffer loss or harm resulting in legal
liability for the person who commits the tortious act, called a tortfeasor. Tort may be intentional
or unintentional.

Intentional or unintentional torts: An intentional tort is a category of torts that describes a civil
wrong resulting from an intentional act on the part of the tortfeasor. Those may be:

Assault: An assault takes place when one person acts intentionally in a way that causes another
person to reasonably apprehend (or fear) an immediate harmful or offensive contact.
Battery: A battery is the intentional harmful or offensive touching of another without consent or
privilege

So, an assault involves the threat of harmful contact, while a battery involves the actual harmful
or offensive touching itself.

Defamation: Defamation is a statement that injures a third party's reputation. The tort of
defamation includes both libel (written statements) and slander(spoken statements).

Invasion of privacy: When a person unlawfully interferes into others private affairs, discloses
his or her private information, publicizes him or her in a false light, or appropriates his or her
name for personal gain.

False imprisonment: Forcibly detains the person or confines his or her freedom of movement.

Fraud: Fraud is an act of dishonesty intended for personal gain or to cause a loss to another
party.

Conversion: It is a voluntary act by one person inconsistent with the ownership rights of
another.

• Trespass to land: It is a common tort or crime that is committed when an individual or the
object of an individual intentionally enters the land of another without a lawful excuse.

Trespass to chattels (personal property): Whereby the infringing party has intentionally
interfered with another person's lawful possession of a chattel (movable personal property). The
interference can be any physical contact with the chattel in a quantifiable way, or whether by
taking it, destroying it, or barring the owner's access to it.

Intentional infliction of emotional distress: It is an intentional conduct that results in extreme

emotional distress of other.

Unintentional torts: An act that results not form an intention to cause harm or to perform some
harmful act, but did not conform his or her conduct to the standard of care required by common
law. These are:

Negligence: It refers to the conduct that falls below the standards of behavior established by law
for the protection of others against unreasonable risk of harm.

Malpractice: Malpractice refers to negligence or misconduct by a professional person such as a

lawyer, a doctor, a dentist, or an accountant. The failure to meet a standard of care or standard of
conduct that is recognized by a profession reaches the level of malpractice when a client or
patient is injured or damaged because of error. All negligence are not malpractice.

Liability: The state of being legally responsible for something.

• Duty and documentation: These are execution of safety measures.

• Breach of duty: Failure to note and report to higher authority about the seriousness

• Causation: Failure to use appropriate safety measures.

Damages: Lengthened hospital stay and need for rehabilitation.

Grossly Unethical Behavior in Community Area

Community programs need to be clear about their own ethical standards, and to hold individuals
to them and to any other standard their professions demand. In most cases, staff members guilty
of grossly unethical behavior should be dismissed as quickly as possible and prosecuted where
that is appropriate - Some of the more familiar types of grossly unethical behavior include:

• Having sexual relationships even consensual sexual relationships with people with whom you
have a professional relationship. Doctor-patient, therapist-client, teacher- student, supervisor-
intern, and youth worker-teen are all examples of such relationships. In some of these cases, a
sexual relationship both violates the professional's code of ethics and may be the base for a
sexual harassment or sexual assault lawsuit as well.

• Exploiting people for financial gain with whom you have a professional relationship As for
example asking money from whom you should give a free service, asking for some free services
he can provide or accepting gifts or money.

Defrauding funders by billing for non- existent services, or inventing problems in order to
deliver unnecessary services.

• Denying necessary medical services to those uninsured and unable to pay

Discriminating in service delivery by race, gender, ethnicity, etc.

• Criminal behavior as redirecting program funds for personal use or sexually abusing children in
a day care center. This can also include criminal behavior that a staff member engages in
criminal activities as selling drugs or equipment.

Professional and Legal Regulation of Nursing Practice

Every state has "nurse practice act" that protects the public define the legal scope. Violation of
rule can result in disciplinary action. Credentialing is the ways in which professional competence
is ensured and maintained. This can be maintained by following processes:

Accreditation: Accreditation is the process in which authorized agencies provide certification of

competency, authority, or credibility.
Licensure: It is the procedure that determines the granting of a license, especially to carry out a
trade or profession.

Certification: It refers to the confirmation of certain characteristics of an object, person, or

organization.

Nursing standards: Standard is a benchmark of achievement which is based on a desired level

of excellence. Standards of care (SOC) measure the degree of excellence in nursing care and
describe a competent level of nursing care.

NURSING STANDARDS

Standards are professionally developed expressions of the range of acceptable variations from a
norm or criterion. They reflect a desired and achievable level of performance against which
actual performance can be compared. Their main purpose is to promote, guide and direct
professional nursing practice (Table 26.1).

Importance of Standards

 Outlines what the profession expects of its members.

 Promotes guides and directs professional nursing practice-important for self-assessment
and evaluation of practice by employers, clients and other stakeholders.
 Provides nurses with a framework for developing competencies.
 Aids in developing a better understanding and respect for the various and complimentary
roles that nurses have.

ANA Standards of Professional Performance

The ANA (American Nurses Association) Standards of professional performance describes a

competent level of behavior in the professional role, including activities related to quality of
care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource
utilization. This serves as objective guidelines for nurses to be accountable for their actions, their
patients, and their peers. The standards provide a method to assure clients that they are receiving
high-quality care, that the nurses know exactly what is necessary to provide nursing care, and
that measure to determine whether the care meets the standards.

Standards Definition Measurement criteria

1 Quality of practice The registered nurse 1. Demonstrates quality by

systematically enhances the documenting the application
quality and effectiveness of of the nursing process in a
nursing practice which actual responsible, accountable and
performance can be compared. ethical manner.
 Their main purpose is to 2. Uses quality improvement
promote, guide and direct activities to initiate changes in
professional nursing practice nursing practice and health
care delivery system.
3. Uses creativity and
innovation to improve nursing
care delivery.
4. Incorporates new
knowledge to initiate changes
in nursing practice if desired
outcomes are not achieved.
5. Participates in quality
improvement activities

1. Participates in ongoing
II: Education The nurse attains know- ledge educational activities related
and competency that reflects to clinical knowledge and
current nursing practice. professional issues
2. Demonstrates commitment
to lifelong learning
3. Seeks experiences to
maintain clinical skills
4. Seeks knowledge and skills
appropriate to the practice
setting.
5. Maintains professional
records that provide evidence
of competency and lifelong
learning,

III: Professional practice The nurse evaluates one's own 1. Engage in self-evaluation
evaluation nursing practice in relation to on a regular basis.
professional practice standards 2. Seeks constructive feedback
and guideline, relevant regarding ones own practice.
statutes. rules and regulations 3. Takes action to achieve
goals identified during the
evaluation process.
4. Participates in systematic
peer review as appropriate.
5. Practice reflects knowledge
of current practice standards,
laws and regulations.
6. Provides age appropriate
care in culturally and
ethnically sensitive manner.
IV: Collegiality The nurse interacts with and 1. Shares knowledge and skills
contributes to the professional with peers and colleagues.
development of peers and 2. Provides peers with
other health care providers as feedback regarding their
colleagues. practice.
3. Interacts with peers and
colleagues.
4. To enhance ones own
professional nursing practice.
5. Maintains compassionate
and caring relationships with
peers and colleagues.
6. Contributes to an
environment that is conductive
to clinical education nursing
students as appropriate.
7. Contributes to a supportive
and healthy work
environment.

V: Collaboration The nurse collaborates with 1. Communicates with the

patient, family, and others in
the conduct of nursing
practice.
patient, significant others, and
health care providers
regarding patient care and
nursing's role in the provision
of care.
2. Collaborates with patient,
family and other health care
providers in the formulation of
overall goals and the plan of
care and in the decisions
related to care and delivery of
services.
3. Partners with others to
effect change and generate
positive outcomes.
4. Document referrals,
including provisions for
continuity of care, as needed.

VI: Ethics The nurse integrates ethical 1. Practice is guided by code

provisions in all areas of of ethics for nurses with
practice. interpretive statement.
2. Maintains therapeutic and
professional patient- nurse
relationship.

VII: Research The nurse integrates research 1. Utilize best available
findings in practice.
VIII: Resource utilization The nurse considers factors 1. Evaluates factors related to
related to safety, effectiveness, safety,
cost, and impact on practice in
the planning and delivery of
nursing services.
3. Delivers care in the manner
of that preserves patient
autonomy, dignity and rights.
4. Seeks available resource in
formulating ethical decisions.
5. Reports illegal,
incompetent or impaired
practice.
6. Maintain patient
confidentiality within legal
and regulatory parameters.
evidence including research
findings to guide practice
decisions.
2. Participates in research
activities as appropriate to the
nurse's education and position
such as the following:
Identifying clinical problems
suitable for nursing research.
 Participating in data
collection.
 Participating in a unit,
organization, or
community research
committee.
 Sharing research
activities with others
conducting research.
 Critiquing research for
application to practice.
 Uses research findings
in the development of
policies, procedures,
and practice guidelines
for patient care.
 Incorporates research
as a basis for learning
effectiveness,
availability and cost when
practice options would
result in the same expected
 patient outcome.
2. Assists the patient and
family in identifying and
securing appropriate and
available services to address
health related needs.
3. Assigns or delegates tasks
as defined by the State Nurse
Practice Acts and according to
the knowledge and skills of
the designated care giver.
4. Assigns or delegates tasks
based on the needs and
condition of the patient, the
potential for harm, the
stability of the patients
condition, the complexity of
the task, and the predictability
of the outcome.
5. Assists the patient and
family in becoming informed
consumers about the cost,
risks, and benefits of treatment
and care.

IX: Leadership The nurse provides leadership 1. Engages on team work.

in the professional practice 2. Works to create and
setting and the profession.
maintain healthy work
environments.
3. Teaches others to succeed
through mentoring.
4. Exhibits creativity and
flexibility during change.
5. Directs coordination of care
across settings and caregivers.
6. Serves in key roles in the
work settings by participating
on committees, councils, and
administrative.
7. Promotes advancement of
the profession.
8. Displays the ability to
define a clear vision, the
associated goals, and a plan to
implement and measure
progress.
 9. Demonstrates energy,
excitement and a passion for
quality work.
10. Willingly accepts mistakes
by self and others, thereby
creating a culture in which
risk-taking is not only safe,
but expected.

In short, nursing standard says:

 Do no harm to patients.
 Respect people.
 Consider and treat everyone as a unique individual.
 Respect patient or caregiver's participation determining what they need.
 Respect everyone's human, civil, and legal rights.
 Do what is best for everyone under the circumstances.
 Don't abuse your position or exploit a participant to gain a personal advantage.
 Don't attempt an intervention in areas in which you're not trained and/or competent.
 Actively strive to improve or correct, to the extent possible, the situations of participants in
your program and the community.

General Ethical Responsibilities

Ethical behavior for a community intervention means actively striving to do what is right for
participants and for the community, and treating everyone of participants, staff members, funders
and the community at large.

Responsibility to funders: Organizers of community program are responsible for being fiscally
accountable, for using funds properly, and for trying to do what they promised to do when took
the money.

Responsibility to staff members: Organizers of community program are responsible for making
sure everyone is treated fairly in all dealings with the program; that everyone is paid for the work
she does, that everyone has a reasonable amount of control over her job; and that everyone has
the opportunity to continue to develop her skills and effectiveness through staff development
and/or supervision. Organizers are also responsible for protecting staff from harm to the extent
possible, and for warning and training them if some physical or other danger is part of their jobs.

Responsibility to participants: Organizers of community program are responsible to provide

the best and most effective services possible. This means constantly searching for better methods
and ideas; paying attention to participant feedback; building on program successes; and
acknowledging, learning from, and correcting program weaknesses. They are also responsible for
respecting participants' rights, and for treating all with the respect due them, not only as program
participants, but also as human beings.

• Responsibility to the community: Organizers of community program are responsible for

trying to understand and meet the needs of the community; for being responsive to community
attitudes and opinions; and trying through intervention, to improve the quality of life in some
way for both program participants and the community as a whole.

It usually makes both ethical and practical sense to involve the target population and/or the
community in planning a community program.

Importance of Ethical Behavior in Community Interventions

By doing right thing, always ethically brings some particular advantages with it. It makes
community program more effective; it secures field worker's stand in the community; it
community allows to occupy the moral high ground when arguing the merits of program, and to
exercise moral leadership in the community.

•Program effectiveness. Consistent ethical behavior can lead to a more effective program.
Considering ethical principles in all aspects of a community intervention leads to find the most
effective and community-centered methods, and brings extra benefit in participation, community
support and funding possibilities.

Standing in the community. An organization that has a reputation for ethical action is far more
likely to be respected by both participants and the community as a whole than one that has been
known to be unethical in the past. An organization that's recognized as ethical is also apt to be
seen as competent, and to be trusted to treat people with respect and to do what it says it will do
that community trust makes it easier to work with community people and to get their
cooperation. Moral credibility and leadership. Ethical action reflects why community
intervention is started. Organizers have a moral obligation to self, the individuals work with
them, and the community to be ethical in all they do, and to expect the same from others. It they
fulfill that obligation, and everyone knows it, community health personnel voice will have
greater impact when they speak out for what they believe is right, or against what they believe is
wrong, and others follow them.

Professional and legal issues: Many of the health and human service professions often involved
in community interventions which are held to specific codes of ethics by their professional
certification or licensure organizations. If members of the profession violate these standards, they
can be disciplined, or even lose their licenses to practice
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