INTRODUCTION

The role of nurses and professional nursing has expanded rapidly

within the past ten years to include expertise specialization, autonomy and

accountability, both form a legal and ethical perspective. This expansion has

forced new concern among nurses and a heightened awareness of the

interaction of legal and ethical principles, labour management and

employment.

Legal Aspects

Nursing is a profession, which is practised in the society involving

people. In every society there are some common as well as statutory laws for

protection of the rights of the people. Therefore for safe Nursing practice

one has to understand the law and legal responsibilities to protect the right of

her clients as well as to protect herself from liabilities.

Thus every Nurse has a personal and ethical responsibility to be aware

of State licensing laws, statutory laws, common law as well as professional

code of ethics for Nurses and changes there on occurring.

Law

Law is a code, which regulates human conduct, capable of being

enforced, and binding to all, so as to bring order the society. It has developed

over the centuries to balance the rights of individual. However laws always

respond to changes, to customs, advancement of technology and needs of the

society. Law imposes a duty on everyone to conform to certain standards of

conduct for the protection of others.

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The basic law of the country is the Indian Constitution. This document

provides power, prescribes functions of the states and lays down

fundamental rights for the citizens of the country.

Purpose of law

To protect the rights of the individuals according to the needs of the

society.

To correct inequalities in the society.

To punish people indulging in forbidden acts.

To define & re- define minimum standards of behaviour in accordance

to the changes that occur in the society.

Constitutional laws

State the fundamental rights of the citizens.

Statutory laws - laws enacted through legislative process are called

statues. They define obligations of the citizen to act in a particular manner.

Criminal laws are mostly statutory which define forbidden acts and the

punishment for commission of such acts.

Common laws are the decisions arising out of judicial process..

Judges hearing a case or controversy decide what law applies to the case &

what law allows and condemns. In judging the case common law decisions

are considered. Judges act as finder of facts and finder of the law.

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Tort - It is the category of law involving civil wrongs against another

person or property. Tort includes negligence, assault, defamation, invasion

of privacy & fraud etc.

Labour laws - These laws lay down rights and obligations between

the employer and the employees. These laws regulate discipline, wages,

leave, pension, gratuity etc. Service laws relating to government officials

differ from laws for private services.

There are different courts as civil court, criminal court, labour court ,

dealing the cases according to the law involved. Supreme Court is the

highest judiciary having highest power in the country.

Professional laws in Nursing

Like any other profession Nursing is also controlled by certain

Regulatory Bodies. A practicing Nurse must follow standards of care which

originate from following sources:

State Nursing Council, which enacts Nurse Practice Acts.

Professional organisations provide guidelines for practice e.g. policy

statement of Trained Nurses’ Association of India.

Employing authorities provide written policies and procedures.

National level regulatory body prescribes professional training courses to

maintain uniformity throughout the country e.g. Indian Nursing Council

(INC)

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1. State Nursing Council

(It is a statutory body established by State law to fulfil the primary

purpose and protection and safeguarding of public. It enacts Nurse Practice

Act, which defines who can practice as a Nurse. A practising Nurse must

follow standards of care originating from Nurse Practice Act. The Act

reserves practice of Nursing for those who have undergone appropriate

training in an institution duly inspected and recognised by the Council or the

authorised Board of Nursing Education. The State Nursing Council thus has

the power to approve and regulate training of Nurse. These Councils register

all qualified Nurses giving them the license to practice according to their

specific training. State Councils also has the power for renewal of license

and its revocation.

2. Professional organisatlons

These organisations give guidelines for practice. Thus Trained

Nurses’ Association has framed the following policy statement for practising

Nurses.

3. Written policies of the employer

Nursing has its own identity as a health profession, hence, due

recognition needs to be given to the role and contribution of Nursing

personnel to health care services in the hospital and the community.

Nursing identity should be reflected in all planning pilpera,

documents, policy statements of government and government organisations

with a view to strenthen1ig development of Nursing, otherwise, this sector

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of the health system gets neglected and status of the Nursing service further

diminished.

Nursing should not be designated as “paramedical”, nor should its

identity be lost under the term “health workers”.

Nursing is supported by auxiliaries. The term “Nursing personnel” can

be used to designate collectively, a wide variety of workers of the Nursing

team, both professionals and Nursing auxiliaries.

All organisations employing Nurses should have, standing orders, job

descriptions, procedure manuals, framed by the competent authorities to

meet the need of the specific organisations. Nurses employed in an

organisatiori must be familiar with these, which should be available to her in

writing.

Indian Nursing Council (INC)

It is also a statutory body established by act of Parliament in 1947. It’s

function is to maintain uniform standard of Nursing education throughout

the country. It prescribes the courses along with their curriculum & ensures

their implementation through inspection of the institutions. The INC Act

1947 was amended in 1986 introducing maintenance of Indian Nurse

Register as mandatory. Thus INC has to maintain a live register with names

of registered Nurses of all the States of India. INC also prescribes the list of

authorities, who can issue the certificate, diploma or degree in- Nursing

which are prescribed by INC. All the State Nursing Councils, two Boards of

Education under Christian Medical Association of India, namely, Mid India

Board of Nursing Education and Board- of Nursing Education South India

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Branch, and Military Nursing Service have been recognised by INC for

award of diplomas and certificates in Nursing.

Negligence

Nurses are responsible for performing all procedures correctly

exerting professional judgement, also when they carryout physician’s orders.

Otherwise Nurse can be cited for negligence and malpractice. They are held

responsible for their own acts which could be acts of commission or

omission. If a Nurse violates criminal statutes & if it is proved that the act is

intentional then the state will bring criminal charges against the Nurse. If not

then civil action for negligence will be implied. Neglect of duty is

established by comparing the act with prevailing standard of care. Standard

of care is determined by establishing how another Nurse will act in a similar

situation. In case of negligence, law is applied from earlier common law

decisions in similar cases as well as from statutes. When similar situation is

not available, reasoning from analogous situation is taken into account.

In case of negligence whether the Nurse or her employer will be sued

depends on the policy of the organisation. A Nurse who acts reasonably

given the circumstances of the time of an emergency, will not be found

guilty of negligence:

To sue for negligence followings must be proved:,

Nurse is legally duty bound to the patient.

The duty performed was short of standard of care by an act• or

omission.

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There, is a causal connection between the act of omission & the

resulting injury, which was forcible.

The client was actually harmed.

Example: The Nurse is legally duty bound to administer medicine in correct

route and dose. She also has to be aware of possible drug reactions. In case a

Nurse fails to administer a drug in correct route, it is a case of negligence.

However there are emergency exceptions. When a bonafied emergency

exists, main question is reasonableness of the action & resource available at

the time of emergency.)

Rights of Clients

Clients as an individual citizen have certain rights which Nurses have

to be aware of for protection of their clients, as well as safeguarding their

own liabilities.

These are as follows:

Rights to a considerate & respectful care.

Right to obtain complete current information regarding his diagnosis,

treatment & prognosis from his physician.

Right to receive relative information before giving consent to any

procedure.

Right to privacy.

Right to refuse treatment.

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Right to receive all communication & record pertaining to care.

Right to receive reasonable response to requests.

Right to know the professionals by name who are treating him.

Right to receive reasonable continuity of care.

Right to inquire & get explanation for the incurred cost.

Right to know the rules & regulations of the institution where .treated.

Right to refuse to participate in research project.

Rights of Nurses

All professionals will also have certain rights. While practicing Nurse

will have the following rights:

Right to a just wage.

Right to work & serve in a safe & healthy work environment.

Right to participate in decisions related to working conditions.

Right to have standard prescribed hours of duty as well as off.

Right to enjoy maternity / paternity leave as per rule.

Right to opportunities for career mobility and continued education.

Right for additional training for working in specialised areas

Where she is accountable for performing specialised care.

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Can refuse or protest formally a physician’s order if she believes it is

harmful for the client.

Right to organise professionally.

Right to political activity.

Consumers Protection Act

The Supreme Court in November 1995 gave a judgement that patients

who receive deficient services by medical profession and hospitals are

entitled to claim damages under Consumers Protection Act 1986. The

concept of the Act is that if a wrong has been committed while giving

service, the care- giver must pay for it. If it is a case of error in judgement

then it has to be proved.

According to the act the consumer need not pay for appealing to

consumers court. The act also prescribes penalties for negligence. However,

the act is not applicable to government hospitals, clinics or health centres

and to those who practice there. This •is because services rendered in

Government institutions are not charged.

Medico Legal Cases

Accidents and injuries including falls & burns.

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As a Community Health Nurse she may witness cases of injury or

‘death by violence or road accidents, she should know that these are medico-

legal cases and. people must be advised to report it to police immediately.

Depending on State law Nurses are also required to report other

criminal activities as child abuse, attempted suicide, homicide, rape,

violence on women etc.

Other legal involvement

An adult can legally give consent to donate specific organs, a Nurse

may be a witness for the same.

Nurses may have to be a witness for client’s “WILL” if it meets all the

legal criteria.

If legal issues are involved, Nurses may have to document all events

connected to death and treating the deceased person with dignity. She also

has to obtain permission for autopsy from nearest relative of the deceased.

Incident reports must be given in occurrence of unusual

• situations when. there is a possibility of legal involvement

Medical Termination Act

Abortions or miscarriages caused by various means, comes under

Criminal Act. Therefore in 1971 Medical Termination Act was passed by the

Parliament to provide some exception in provision of the penal code act.

According to this act abortion can be done only in case of pregnancy, not

exceeding 12 weeks & is carried out at a licensed clinic or hospital by a

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licensed medical practitioner. Beyond 12 weeks of gestation, abortion can be

done only with consent of two licensed doctors agreeing that continuation of

the gestation is threatening to the life of the pregnant women.

Community Health Nurse has to be aware of this act so that act she

can prevent illegal abortions in the community, and guide pregnant mothers

to a licensed clinic or hospital when necessity arises.

Standing Order

Community Health Nurse who works independently in a community,

is unlike the Nurse working in a hospital setting. For sometimes, in an

emergency, she may have to perform certain activities, which she normally

does not perform without the doctor’s order. Therefore, to shoulder such

responsibilities at the time of emergency, there is need ,for standing orders

or instructions, by .the authority, which will provide legal protection to the

Nurse in case of any controversy.

Each organisation has it’s own standing orders usually prepared

jointly by the authority & the Nurse. It is expected that the Nurses use

the .standing orders only at the time of emergency. If there is any doubt, the

standing orders should not be carried out. After carrying out the standing

orders, it should be recorded immediately with signature,, date, time & to be

brought to the notice of the Medical Officer or her supervisor as early as

possible.

Examples: Injection Methyl Ergometrine, 0.2 mg IM may be a

standing order for the ANMs, to be ‘given when the placenta has not

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separated within.5-i0 minutes of delivery of-the baby or-excessive., bleeding

starts with or without expulsion of placenta.

In case of eclampsia, there could be a standing order for ANMs to

give in-between fits, diazepam 10 mg orally & nephadipin 10 mg crushing

& giving under the tongue.

ANMs have standing orders for administering CO-trimoxazole tablet

to children in specific doses, in case of ARI. There is a standing order for

ANMs/FHWs for administration of antimalarial drugs.

Points to be remembered

Be sure of standing orders given in writing.

If there is any doubt refrain from carrying out standing orders, till it is

clarified.

Record immediately with signature, date and time.

Do not leave your client, keep a watch for some time.

Give necessary instructions to a responsible family member before

leaving your client.

Report to your supervisor or medical officer as early as possible for

information & support.

Records & Reports

These are very important documents to provide support to a / PFIN for

the services she is giving. These will be permanent documents to show the

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supervision performed, meeting held, visit done, and various other activities

performed.

Records and reports help to:

Review the work done.

Follow the progress.

Plan services for the future.

Helps in communication between the workers.

Serve as a tool for evaluation of services.

Provides data for research.

Reports & records, to be maintained, is always spelt out by the.

authority. It may differ in different organisations.

Records to be maintained by PHN

Diary for all daily activities.

Tour diary.

Records of any specific activities which may be demanded for e.g.

IUCD insertion, immunisation given etc.

Home visits

Reports to be prepared by PHN

Advance report of weekly or monthly programmes planned.

Advance tour programme.

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Monthly report of performances of ANMs on FHS under her

supervision.

Evaluation report of each worker under her supervision.

Annual report of all activities performed by herself & by her

subordinates.

Any specific report demanded by the authority,

Special points to be remembered:

Writing must be eligible.

Neatness and tidiness is essential.

Never over write.

Whenever scratching out any writing, initial it.

Write short sentences.

Write only the essentials, avoiding redundancy.

Write to the point.

Sign at the end of reports and records with dates.

Remember that records and reports are also legal documents, hence to

be kept properly in safe custody.

Points to be remembered for maintaining records and reports:

Have to be accurate & complete.

Documented at the time of actual occurrence.

Clear & eligible.

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Written concisely without eliminating important points.

Easily available.

Authenticated with signature and date.

Professional Responsibilities of a Nurse

They are responsible for confirming that informed consent has been

obtained from the patient or his guardian before any surgery or other.

medical procedure is performed. However, in emergency situation it is

exempted if it is impossible to get to obtain such consent from the client or

his authorised person.

Nurses are obliged to follow physicians orders unless they believe that

the orders are wrong arid could cause harm to the client. Here Nurse has to

make formal report explaining her refusal to carry out the order.

Nurses should speak and act carefully to her client to avoid

apprehensions, otherwise it can be considered as an assault and thus become

a punishable act.

Before carrying out any physical procedures Nurse has to obtain

informed consent from her client. Otherwise it will be unlawful, meaning

willful touching of other’s body.

Nurses require additional training and ongoing in-service education

for practising in specialised areas e.g. neurology, critical care, intensive

cardiac care, care carrier etc. as they are legally accountable for carrying out

the specialized duties and related to advanced technologies.

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Nurse patient ratio has been standardised centrally as well as State—

wise. It has already been prescribed by INC as well as by TNAI. If a Nurse

has been forced to care for patients more than what is reasonable, she has.the

right to bring it to the notice of the Nursing administration.

A registered practsing Nurse can never refuse from her service when

she is called at the time of emergency by responsible authorities

LEGAL RESPONSIBILITIES OF NURSE

Responsibility of Appointing and Assigning

Nursing administrators are expected to be aware of appointment and

assignment A Manager who departs from agency’s hiring policies can be

held negligent if she or her appoints an employee, without appropriate

screening and that employee later injures a patient. The nurse administrators

have responsibility for staffing and supervising nursing units to ensure safe,

effective patient care) Therefore they have the authority to temporarily

reassign a nursing employee from one unit to another to compensate for

emergency staff shortages. In shifting an employee to compensate for

personnel shortage, a supervisor or manager must take into consideration the

nurse’s capability to discharge duties of the temporary position. In floating

nurses to an intensive care unit to compensate for understaffing, the manager

should reassign only those nurses whose education and experience have

prepared them to perform all of the nursing functions common to an

intensive care unit.

Each nurse has legal responsibility to make full disclosure of her or

his background knowledge and skills and notify the nurse manager when

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given an assignment for which she or he is not qualified. The manager is

also obliged to adjust the amount and type of supervision to fit and

employees level of maturity and experience. Less experienced or less skilled

employees need more professional support and advice from the manager.

Responsibility in Quality Control

The nursing administrator and the authority of the agency at all levels

have a legal obligation to ensure nursing 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.

Usually the head nurse or ward in charge is responsible for quality of patient

care given by all personnel including medical on the nursing unit, whether or

not these individuals have direct reporting responsibility to the head nurse.

Responsibility for Equipment

To protect patients and employees from injury, a nurse manager must

ensure that all patient care equipments are fully functional and that defective

equipment is promptly repaired or replaced; He/she must ensure that nursing

personnel know how to operate sophisticated equipment, so that he/she is

expected to provide instructions in proper care and storage of patient care

equipment, even then, there is a service contract providing for maintenance

by an outside contractor. Nurse also have duty to refuse to use equipment

known to be faulty or that was not designed for use in the situation where it

was ordered.

Responsibility for Observation and Reporting

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Nursing personnel have more frequent and prolonged patient contact

than other care-giver. Nurses are trained to detect significant symptoms and

reactions. Consequently nurses have a legal duty to observe patients

frequently and report findings that have diagnostic or treatment value for the

patient’s physician and other members of the patient’s treatment team. The

nurse is expected to observe a patient more closely when his or her condition

implies increased health risk. Infants, children, aged, disoriented psychiatric

and critically ill patients require more frequent observation than other

patients with no evidence of impending respiratory or cardiac emergency.

The nurse has a duty to record and report observations of a patient’s

condition promptly, so that the physician can base treatment, decisions on

up-to-date information about the patient’s health needs. When the patients

condition deteriorates to the point that immediate action is needed to save

life or limb, the nurse must report observations of the patient’s worsening

conditions to the concerned doctor in person or any means. The nurse has a

duty to report improper medical care through appropriate channels in order

to protect patients from Doctor’s negligence.

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

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threatens violence to others is discharged or escapes from the health care

agency. The manager must ensure that nursing personnel follow the

procedures to alert community members to the presence of a potentially

dangerous patient in their midst.

Responsibility for Record Keeping and Reporting

Nurses have legal responsibility for accurately reporting and recording

patients conditions, treatments and responses to care. The medical record is a

written or computerised account of a patient’s illness and treatment that

includes information submitted by all members of the patients health care

team: The medical record is an information source document that should be

used to plan care, evaluate care, allocate costs, educate personnel, research

care measure, and substantiate legal claim.

Patients medical record is essential to proper care, and it is the

property of the Health care agency. However, patient has a property right to

information contained in the report; the patient has right to inspect and copy

the record after being discharged. However, It is not advisable to allow a

patient to review his or her medical record without medical supervision and

explanation, because patient is likely to misunderstand certain record

notations.

Failure to record significant patient information in the medical record

makes a nurse guilty of negligence when the patient is injured because of

physicians/surgeons ignorance of significant information almost medical

history, signs and symptoms. The medical record must be accurate to

provide a sound basis for care planning. Therefore, errors in nurses charting

must be corrected promptly in a manner that leaves no doubt about the facts.

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Every health care agency should have a policy and protocol that direct

that an erroneous chart entry be crossed through, labelled or erroneous,

signed by the employee who correct the error and retained in the patients

record. Correct information should then be documented to replace the

erroneous data. Pages of the record that contain erroneous and corrected

entries should never be destroyed. Nurses who conspire with Doctors and

others to falsify patient record for purposes of concealing a criminal

violation may be found criminally liable

All health personnel require to report certain incidences to concerned

authorities such as child abuse, ophthalmia neonatarum - infant

phenylketonuria, communicable diseases births out of wedlock, gunshot

wounds, suicide, rape and use of unprescribed narcotics. h reporting

information about criminal acts obtained during patient care, the Nurse must

reveal such information only to the police, because it is considered a

privileged communication.

Responsibility for Death and Dying

There are many issues surround the events of death. Death occurs

when there is an absence of brain function, despite functions of other body

organs. However, Nurses must be aware c legal definition of death because

they must document all events that, when the patient is in their care.

Sometime there will be issues of enthanasia, either active or passive. Active

enthanasia is defined as intentional homicide, e.g. intentionally

administering a lethal dose of morphine to a patient to cause death. An

example of passive enthanasia includes, removing breathing support or

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withholding blood transfusion from a terminally ill patient with irreversible

brain damage, may raises legal questions.

In addition, documenting all events surrounding death, Nurses have

other specific legal duties which include, treat a deceased person with

dignity (wrongful handling is a ground for a lawsuit) and obtaining consent

for an autopsy from the decedent (before death) or a close family member

(after death). A competent adult can legally give consent to denote specific

organs and nurses may serve as an witness to this decision.

CONCLUSION

So, far we have discussed legal aspects and legal responsibilities of

Nurse and Rights of Nurse and Rights of the clients.

BIBLIOGRAPHY

1. B.T. Basavanthappa (2002) “Nursing Administration”, New Delhi J.P.

Brothers.

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2. Anitha W. Finkelman (2009) “Leadership and management in

Nursing”, First ed, Pearson, India.

3. Ann Marriner – Tomey (1992) “Guide to Nursing Management”, 4th

Edition, Mosby.

4. Ruth M. Tappen (2001) “Nursing Leadership and Management

Concepts and pratice, 4th Ed., Davis,.

5. Bessie L. Marquis (2009) “Leadership roles and management function

in Nursing”, 6th Ed, Wolters Kluwer.

6. Indian Nursing Council, “Teaching Material for Quality Assurance

Model” – 2006.

7. Net source

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