Texas Nursing Jurisprudence and Ethics _________________________________________________________
There are also a variety of legal issues that affect the provi- sion of nursing care and maintenance of a nursing license. It is important to note that, although possibly related, the laws governing nursing practice are different from the ethical framework(s) that nurses use to guide decision making. Laws pertaining to documentation, licensure, and standards of care have been established to ensure that nurses practice within a defined scope of practice and are aware of the boundaries of independent nursing action and responsibilities. These laws also act to hold nurses accountable for maintaining an acceptable standard of patient care. However, perhaps the greatest legal concern for nurses is the threat of negligence or malpractice claims. The tort (or medical malpractice) liability system is intended to provide deterrence to clinicians who willful or negligently injure patients; deterrence is theoretically achieved by holding practitioners legally liable for their actions or omissions [12]. According to tort law, four elements must be established for a ruling of malpractice [13]: • Duty: The nurse owed a duty to meet a particular standard of care. • Breach of duty: The nurse failed to perform the owed duty. • Causation: There is a causal connection between the nurse’s failure and the patient’s injury. • Damages: An injury occurred for which monetary compensation is adequate relief. These elements must be shown by a “preponderance of the evidence,” defined as more than 50% probability, a lower stan- dard than the “beyond a reasonable doubt” used in criminal law [14; 15]. Malpractice cases are decided on the basis of what a “jury is likely to think is fact” rather than actual fact [16].
ETHICAL AND LEGAL ISSUES IN NURSING PRACTICE
In addition to their legal obligations, nurses have ethical obli- gations to their patients. The practice of nursing is primarily one of caring, and the ethical theories for nursing are often referred to as “the ethics of caring.” Nurses are expected to address both ethical and legal issues in their practice, which can be complex. As medical advancements and new technology progress, these must be incorporated into established ethical standards. The American Nurses Association has established the Code of Ethics for Nurses, which is intended to act as “the ethical standard for the profession and provides a guide for nurses to use in ethical analysis and decision-making” [11]. The full text of this Code is available at https://www. nursingworld.org/practice-policy/nursing-excellence/ethics/ code-of-ethics-for-nurses. Major ethical issues that may arise in the practice of nursing are related to the provision of patient-centered care, advocacy, del- egation, self-care, and supporting colleagues and the profession [11]. Ethical concepts central to patient-centered care include advocacy, confidentiality, privacy, self-determination, and the dignity and worth of all persons. Ethical concepts central to nursing practice include accountability (i.e., accepting respon- sibility for one’s action or inaction), beneficence (i.e., the duty to do good), competence (i.e., only performing duties within one’s scope of practice, acquiring new skills and education), nonmaleficence (i.e., the duty to do no harm), veracity (i.e., truthfulness), and social reform (e.g., advocating for patients and groups). Additionally, as a nurse gains experience in his or her field and specialty, the ethic of teaching comes into play. This can simply involve helping an inexperienced nurse grow by passing along knowledge, or can involve more specific leadership, supervisory, or teaching roles. Several ethical issues are addressed in the Texas Board of Nursing Position Statements [9]. These include the issue of initiation of cardiopulmonary resuscitation (CPR) in long-term care residents in the absence of a do not resuscitate (DNR) order (e.g., when initiation of CPR would appear futile and inappropriate given the nursing assessment of the resident, despite the premise that a DNR order may only be given by a physician). Other ethical issues discussed in the Position Statements include care of those with whom the nurse has a personal relationship and issues of patient confidentiality and privacy with regard to the use of social media. Reading, thought, and discussion about ethics and potential ethical dilemmas can help nurses respond appropriately and can help prevent unethical behaviors from occurring in the workplace.
PROFESSIONAL BOUNDARIES AND UNPROFESSIONAL CONDUCT
Another facet of ethical care and practice involves maintaining appropriate limits in the nurse/patient relationship. Based on the idea that there is an imbalance of power and potential for abuse in this relationship (due to the nurse’s power and the patient’s vulnerability), the State of Texas requires all nurses to be familiar with and abide by the laws and rules regarding the limits of the nurse/patient relationship [3; 17]. Nurses should strive to promote the patient’s best interests, dignity, and independence and refrain from inappropriate involvement in the patient’s personal relationships and/or the obtainment of personal gain at the patient’s expense. Violating professional boundaries of the nurse/patient relationship includes, but is not limited to, emotional, financial, physical, or sexual exploita- tion of the patient or the patient’s family [16]. These violations and other types of unprofessional conduct are grounds for disciplinary action by the Board.
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