Chapter 4 Ethics and Laws Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Introduction The following serve to protect patients and residents from harm: Nurse practice acts Your training and job description Safe delegation A complex set of rules and standards of conduct The ethical and legal aspects of care are formed by a complex set of rules and standards of conduct. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ethical Aspects Ethics is knowledge of what is right conduct and wrong conduct. Morals are involved. It deals with choices or judgments about what should or should not be done. Ethical behavior involves not being prejudiced or biased. Ethical problems involve making choices. Professional groups have codes of ethics. An ethical person: Behaves and acts in the right way Does not cause a person harm To be prejudiced or biased means to make judgments and have views before knowing the facts. Do not judge the person by your values and standards. Do not avoid persons whose standards and values differ from your own. You must decide what is the right thing to do. The ANA and the NFLPN have code of ethics for RNS and LPNs/LVNs. Review the contents of Box 4-1 on p. 35 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ethical Aspects (cont’d) Boundaries Professional boundaries separate helpful behaviors from behaviors that are not helpful. The following can occur when you are over-involved or under- involved with the person. Boundary crossing—A brief act or behavior outside of the helpful zone Boundary violation—An act or behavior that meets your needs, not the person’s needs Professional sexual misconduct—An act, behavior, or comment that is sexual in nature A boundary limits or separates something. As a nursing assistant, professional boundaries are formed as you help patients, residents, and families. Boundary crossing: the act may be thoughtless or something you did not mean to do. Boundary violation: the act or behavior is not ethical; it violates the code of conduct. Examples include abuse, giving a lot of information about yourself, keeping secrets with the person. Professional sexual misconduct is present even if the person consents or makes the first move. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Ethical Aspects (cont’d) Boundary signs are acts, behaviors, or thoughts that warn of a boundary crossing or violation. Be alert to these signs. Some violations and some types of sexual misconduct also are crimes. To maintain professional boundaries: Review the code of conduct in Box 4-1 on p. 35 in the Textbook. Follow the rules in Box 4-2 on p. 36 in the Textbook. Review the contents of Box 4-3 on p. 36 in the Textbook. Review the Focus on Communication: Professional Boundaries Box on p. 36 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects Ethics Laws What you should or should not do Tell you what you can and cannot do A law is a rule of conduct made by a government body. Criminal—generally offenses against the public and society Civil—concerned with relationships between people The U.S. and state legislatures make laws. Enforced by the government, laws protect the public welfare. An act that violates a criminal law is called a crime. A person found guilty of a crime is fined or sent to prison. Civil laws are those that involve contracts and nursing practice. A person found guilty of breaking a civil law usually has to pay a sum of money to the injured person. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects (cont’d) Torts A wrong committed against a person or the person’s property Part of civil law Unintentional—harm was not intended Intentional—harm was intended Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects (cont’d) Unintentional tort Negligence Malpractice is negligence by a professional person. Intentional tort Defamation—injuring a person’s name and reputation by making false statements Libel—made in print Slander—made orally Unintentional tort: the negligent person did not act in a reasonable and careful manner. As a result, a person or the person’s property was harmed. The person causing the harm did not intend or mean to cause harm. What you do or do not do can lead to a lawsuit if harm results to the person or property of another. You are legally responsible (liable) for your own actions. Intentional tort: the act is done on purpose and is meant to be harmful. Never make false statements about a patient, resident, family member, co-worker, or any other person. Examples of defamation are implying or suggesting a person uses drugs, saying a person is insane or mentally ill, or implying or suggesting a person steals money from the staff. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects (cont’d) Intentional torts (cont’d) False imprisonment—unlawful restraint or restriction of a person’s freedom of movement Invasion of privacy—private affairs exposed or made public without consent Health Insurance Portability and Accountability Act of 1996 (HIPAA) Fraud—saying or doing something to trick, fool, or deceive a person Assault and battery—may result in both civil and criminal charges Examples of false imprisonment are threatening to restrain a person, restraining a person, or preventing a person from leaving the agency. You must treat the person with respect and ensure privacy. Only staff involved in the person’s care should see, handle, or examine his or her body. Review the contents of Box 4-4 on p. 38 in the Textbook. HIPAA protects the privacy and security of a person’s health information. Failure to follow HIPAA rules can result in fines, penalties, and criminal action including jail time. Fraud is telling a person or family that you are a nurse, so is giving wrong or incomplete information on a job application. Assault is intentionally attempting or threatening to touch a person’s body without consent and battery is actually touching a person’s body without his or her consent. Consent is the important factor in assault and battery. The person has the right to withdraw consent at any time. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects (cont’d) Informed consent Consent is informed when the person clearly understands: Reason for treatment, procedure, or care measure What will be done How it will be done Who will do it The expected outcomes Other treatment, procedure, or care options The effects of not having the treatment, procedure, or care measure A person has the right to decide what will be done to his or her body and who can touch his or her body. The doctor is responsible for informing the person about all aspects of treatment. A responsible party may give informed consent for a person unable to do so. This can be a wife, husband, parent, daughter, son, or legal representative. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Legal Aspects (cont’d) Wills You can ethically and legally witness the signing of a will. You can refuse to witness the signing of a will. You must politely refuse to prepare a will. Know your agency’s policy before you agree to witness a will. If you have questions, ask the nurse. A will is a legal document of how a person wants property distributed after death. Do not witness the signing of a will if you are named in the will. If you are a witness, be prepared to testify that the person: Was of sound mind when the will was signed Stated that the document was his or her last will If you witness a will, tell the nurse. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse Elements of abuse Willful infliction of injury Unreasonable confinement Intimidation Punishment Depriving the person (or the person’s caregiver) of the goods or services needed to attain or maintain well- being Involuntary seclusion Abuse is the intentional mistreatment or harm of another person. Abuse causes physical harm, pain, or mental anguish. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Abuse is a crime. It can occur at home or in a health care agency. All persons must be protected including those in a coma. The abuser is usually a family member or caregiver. Both men and women are abusers. Both men and women are abused. Many states, accrediting agencies, and OBRA do not allow agencies to employ persons who were convicted of abuse, neglect, or mistreatment. The abuser can be a friend, neighbor, landlord, or other person. Before hiring a person: The agency must thoroughly check the applicant’s work history. All references are checked. Efforts must be made to find out about any criminal records. The agency checks the nursing assistant registry for findings of abuse, neglect, or mistreatment and of mis-using or stealing a person’s property. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Vulnerable adults Persons 18 years old or older who have disabilities or conditions that make them at risk to be wounded, attacked, or damaged They have problems caring for or protecting themselves due to: A mental, emotional, physical, or developmental disability Brain damage Changes from aging Patients and residents, regardless of age, are considered vulnerable. Older persons and children are at risk for abuse. Review the Focus on Long-Term Care and Home Care: Vulnerable Adults Box on p. 40 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Elder abuse—any knowing, intentional, or negligent act by a caregiver or any other person to an older adult Forms of elder abuse Physical abuse • Neglect Verbal abuse • Involuntary seclusion Emotional or mental abuse • Sexual abuse Abandonment Financial exploitation or misappropriation Federal and state laws require the reporting of elder abuse. A negligent act causes harm or serious risk of harm. Review the signs of elder abuse in Box 4-5 on p. 41 in the Textbook. If abuse is suspected, it must be reported. If you suspect abuse, discuss the matter and your observations with the nurse. Give as many details as possible. Review the contents of Box 4-6 on p. 41 in the Textbook. Review the Focus on Long-Term Care and Home Care: Elder Abuse Box on p. 42 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Child abuse and neglect May involve the following: A child 18 years old or younger Any recent act or failure to act on the part of a parent or caregiver The act or failure to act results in death, serious physical or emotional harm, sexual abuse, or exploitation. The act or failure to act presents a likely or immediate risk for harm. Child abuse and neglect occurs at every social level: low-, middle-, and high-income families. The abuser’s education level may be low to high. The abuser is often a household member: parent, a parent’s partner, brother or sister, nanny. Usually an abuser is someone the family knows. Risk factors include stress, family crisis (divorce, unemployment, moving, poverty, crowded living conditions), drug or alcohol abuse, abuser history of being abused as a child, discipline beliefs that include physical punishment, lack of emotional attachment to the child, a child with birth defects or chronic illness, a child with personality or behaviors that the abuser considers “different” or not acceptable, unrealistic expectations for the child’s behavior or performance, families that move often and do not have family or friends nearby. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Types of child abuse and neglect Physical abuse Physical or emotional neglect Sexual abuse Rape or sexual assault Molestation Incest Child pornography Child prostitution Emotional abuse Substance abuse Abandonment Child abuse and neglect has many forms. Often more than one type is present. Physical abuse is injuring the child on purpose. Physical neglect means depriving the child of food, clothing, shelter, and medical care. Emotional neglect is not meeting the child’s need for affection and attention. Sexual abuse is using, persuading, or forcing a child to engage in sexual conduct. Emotional abuse is injuring the child mentally. Substance abuse is part of child abuse and neglect in some states. It involves: exposing a child to the making, selling, and or distributing of a controlled substance and any equipment and related activities, the selling, distributing, or giving drugs or alcohol to a child, using a controlled substance by a caregiver that impairs his or her ability to adequately care for the child. Abandonment is when a parent’s identity or whereabouts are unknown. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Report any changes in the child’s body or behavior. Child and parent behaviors may signal a problem. The child may be quiet and withdrawn. The child may fear adults. Sometimes children are afraid to go home. Sudden behavior changes are common. Bed-wetting, thumb-sucking, loss of appetite, poor grades, running away Some children attempt suicide. Review the contents of Box 4-7 on p. 43 in the Textbook. The health team must be alert for signs and symptoms of child abuse. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Child abuse is complex. Parents give different stories about what happened. Frequent emergency room visits are common. All states require the reporting of suspected child abuse. If you suspect child abuse, share your concerns with the nurse. Give as much detail as you can. Parents blame injuries on play accidents or other children. You must be alert for signs and symptoms of child abuse. All states require reporting of suspected child abuse. However, someone should not be falsely accused. Share your concerns with the nurse. The nurse contacts health team members and child protection agencies as needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting Abuse (cont’d) Domestic abuse (domestic violence) occurs in relationships. One partner has power and control over the other through abuse. Abuse may be physical, sexual, verbal, economic, or social. Usually more than one type of abuse is present. Patients and residents can suffer from domestic abuse. State laws vary about reporting domestic abuse. If you suspect domestic abuse, share your concerns with the nurse. Domestic abuse is also called domestic violence, intimate partner abuse, partner abuse, and spousal abuse. Domestic abuse is a safety issue. The victim often hides the abuse. He or she may protect the abuser. The health team has an ethical duty to give information about safety and community resources. Review the Focus on Long-Term Care and Home Care: Domestic Abuse Box on p. 44 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.