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Professional, Ethical & Legal Issues in Nursing Practice

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    Singapore Nursing Board Standards for Nursing Practice defines that Nurses/midwives have the professional responsibility and accountability to uphold Standard of care and to contribute to their dissemination, interpretation and development despite medical advances, social and demographic changes and an increasingly complex healthcare delivery system that challenge the ability of nurses to provide safe quality of care. Should nurses fail to uphold certain standards and by doing so cause harm or injury to the client, they would be held liable in the tort of negligence.

    Description of a practical situation which raised ethical issues: Mr Lim 70 years old has been hospitalised for medical treatment with the diagnosis of chronic heart failure. He was ordered intravenous therapy by Dr Peter the medical resident. Nurse Su questions the order because it is for an infusion of Dextrose 50%. Dr Peter tells her that he checked it with Dr Lee, the medical officer. Nurse Su checks it with Nurse May before administration. Later, Mr Lim has a cardiac arrest and suffers extensive brain damage as a result of the infusion.

    The hospital inquiry is held and it determined that the correct infusion would be Dextrose 5%. Mr Lim’s family members are very upset and seek legal advice. All names mentioned in the above scenario are pseudonym. Identification of the ethical issues within the situation: Negligence Negligence is the breech of an obligation or duty to act with care, or failure to act as a reasonable or prudent person under certain circumstances. Negligence is established as an unintentional tort alleged when one may have performed or failed to perform an act that a reasonable person would or would not have done in similar circumstances. Judson & Harrison, 2010, p. 69). To enforce tort of negligence, the basic elements of tort of negligence must be established –duty, dereliction, direct cause and damages. (Judson & Harrison, 2010, p. 101) Negligence is one of the most important torts and would enable patients who have suffered foreseeable harm as a result of a nurse’s carelessness to sue for compensation (Martin, 1996). A nurse or doctor could be negligent if a patient is harmed because of ignorance of well-accepted and well-know published nursing and medical research findings (Tingle, 2002).

    Hence both nurses and doctors are negligence and malpractice their professionals then cause Mr Lim suffered brain damage. The tort of negligence means “a person suffered an injury to his or herself as a result of another’s act or omission, which fell below the expected standard of care” (Crisp & Taylor (2000), p- 427). “for someone to be found negligence in any situation, the claimant need to prove each one of the three essential components of tort, namely existence of a duty of care, breach of the duty and as a result of the breach, the victim suffers damage” (Corcoran (2000), p- 280 ).

    The fundamental principle of negligence is “that the party complained of should owe to the party complaining a duty to take care and that the party complaining should be able to prove that he has suffered damage as a consequence of a breach of that duty” (Staunton & Chiarella, 2003, p-36). Therefore nurse can be held liable for professional malpractice if their patients suffer harm from the treatment given. Ethics Ethics is a systematic approach that uses as moral justification to define what should or should not to be done. Ethics is prescriptive; it refers to what we should do than what we actually can do.

    Ethics is relevant to all individuals and moral concepts, and principles and action guides should apply to all persons equally (Staunton & Chiarella, 2003). Ethics can apply to prevent negligence or malpractice. Beauchamp & Childress (2001) stated that the four major principles theories which establish prima facie obligations: which are autonomy, beneficence, non-maleficence, and justice. Autonomy Autonomy is “the right to self-determination, particularly in relation to one’s right to consent to treatment and to receive information about one’s treatment” (Staunton & Chiarella (2003), p-29).

    Harris (2005) defines autonomy is the ability of a person to control their own life and to some extent their own destiny. He moreover mentioned that patients have the right to refuse and non-compliance is not unusual. However, Mr Lim was not received the treatment information and do not have a chance to refuse or decide regarding his treatment plan he received. Beneficence Beneficence means that acting in the patient’s best interest and to do good always (Hendrick, 2000). Beauchamp & Childress (2001) define the beneficence as a moral obligation to act for the benefit of others.

    According to Nursing and Midwifery Council Code (2002) stated that “the nurse is called to uphold and protect the patient’s interests and well-being, maintain and improve his/her knowledge and competent to serve the interests of society”. Nevertheless both nurses are instead of to uphold and protect the patient well-being, because of their negligence and malpractice Mr Lim has cardiac arrest and develop brain damage. Non-maleficence Beneficence Non-maleficence means “to do no harm” and negligence occur when the nurse owed a duty of care to patient (Hendrick, 2000).

    When a patient was admitted to hospital for treatment, the hospital and its staff owe a duty of care to patient (Tay, 2001). Non-maleficence is “the principle in health care and forms the basis of the nurses’ duty to take care in the way do no harm in which they look after their patient” (Staunton & Chiarella,2003, p-29). The nurse owes the patient a duty of care and need to act in accordance with this duty at all times (Nursing and Midwifery Council Code, 2002) Therefore, Dr Peter, Nurse Su and May are owed a duty of care and “to do no harm” to Mr Lim under their care.

    But Mr Lim had suffered the brain damage due to both doctors and nurses negligence and malpractice their professional. Justice Justice has two meaning in ethics such as justice as fairness and justice as an equal distribution of burdens and benefits. Justice as fairness implies and expects a level of impartiality and neutrality in dealing with others and justice as an equal distribution of burdens and benefits is often used to address questions relating to resource allocation (Staunton & Chiarella, 2003).

    Beauchamp & Childress (2001) refer to justice as an equal distribution of burdens and benefits or distributive justice— the patient receiving the healthcare to which he/she is entitled. Wilmot (1997) argued that justice is also the right to be able to express and opinion freely and for it to be weighed by the hearers in an unbiased way. Nursing and Midwifery Council Code (2002) requires the nurse to continue to care for patients, respecting their involvement, and not to judge whether or not the patient deserves treatment based on his/her behaviour (Wilmot, 1997).

    Breach of duty Breach of duty is “the failure to exercise the care and skills ordinarily used in like situations by skill members of nursing profession practicing their profession in a particular situation” (Cournoyer (1989), p-143). Responsibility and accountability “ nurses demonstrate professional conduct and practice in accordance with standards of nursing practice determined by the regulatory board and accept that the primary duty is to ensure safe, competent and ethical nursing care to the client” (Singapore nursing board( 2011), standard 2).

    Therefore, the above scenario both nurses have pharmacological deficits and failed to check the five rights when serving medications. This showed that they failed to “constantly strive to acquire knowledge and skills to provide evidence-based practice and improve the quality of care” (Singapore Nursing Board (2011), Standard 3). Nurse Su failed to monitor Mr Lim’s condition after administering the intravenous Dextrose 50%. Both nurses had breached in their duty of care to Mr Lim and this failure to act could continue malpractice.

    Staunton & Chiarella (2003) described the four major of bioethical principles such as Autonomy, Non-maleficence, Beneficence, and Justice. Non-maleficence is the principle of “above all, do no harm” (p. 29). However, the above scenario both nurses were ignored the bioethical principles of non-maleficence and harmed Mr Lim to suffer cardiac arrest and brain damage due to medication error. Beneficence is the principle of “above all, do well” (Staunton & Chiarella (2003), p-29). Therefore, nurses and doctor who are taking care of Mr Lim must do good things under their care or treatment.

    Beauchamp & Childress (1996) argued that our duty to do no harm is greater than our duty to do well, particularly where our duty to do well may put others or ourselves at risk. According to Staunton & Chiarella stated that “a nurse have a right as a professional and legal obligation to question doctors orders, if she believes the treatment ordered is inappropriate/ incorrect or the patient has not been adequately informed about the consequence of the particular treatment” (p-69).

    Nurse Su was question Dr Peter regarding the treatment ordered before she administrates the medication to Mr Lim, but she was not escalating up to check with the consultant or pharmacist regarding in doubt of medication. Dr Peter has also breached in his duty of care as he failed to perform according to the standards required of a medical resident who was working in the medical ward. When Nurse Su questions the orders, it should make Dr Peter check twice the orders on whether he wrote on the inpatient medical records as IV dextrose 50% instead of IV dextrose 5%.

    Dr Peter should not shift his responsibility by just verbalising that he had checked with Dr Lee. Dr Lee would also be liable if he advised Dr Peter to administer dextrose 5o%. Dr Peter could even check with the pharmacist regarding the orders when in doubt. Damage Damage is the main action in negligence “three particular types of damage that the courts will recognise and, if proved to exist, will compensated for physical, financial, and psychological damage” (Staunton & Chiarella (2003), p-73).

    The relationship between the damage and the negligent act “requires that there be a direct or causal relationship between the defendant’s breach of his or her duty of care and the plaintiff’s damage. The breach must cause the damage, otherwise no compensation will be awarded” (Staunton & Chiarella (2003), p-76). Physical damage “refers to the obvious physical injuries sustained by plaintiff, which are generally easily identified” (Staunton& Chiarella (2003), p-74).

    The above scenario, as a result of the medication error, Mr Lim suffers from cardiac arrest and extensive brain damage. It could be permanent. Hence, Mr Lim encountered the financial damage because of needs to stay in hospital longer and this could incur in the cost of his treatment. Furthermore, in the long term, some of Mr Lim’s family member would have to quit job to look after Mr Lim resulting in loss of income or require a maid to look after Mr Lim for long term care, which can be costly. Mr Lim may also require further hospitalisation regarding his health condition.

    Psychological damage “refer to as nervous shock and is an area of damage becoming increasingly recognised by the courts, nervous shock as a form of damage is that whatever is directly experienced by, observed by the plaintiff causes the plaintiff to suffer ongoing psychological damage, such as a chronic neurosis or depression which can be medically established” (Staunton & Chiarella, 2003, p-74). The family members of Mr Lim could suffer from psychological damage from the experience they encountered regarding Mr Lim’s health condition. Staunton & Chiarella (2003) described that the specific damages and general damages.

    General damages “which cannot be specifically quantified in monetary amounts, such as pain and suffering, and loss of enjoyment of life, now and in the future” (p-81). Mr Lim was suffered the general damage for his life due to both doctors and nurses negligence/malpractice under their care. Vicarious Liability Staunton & Chiarella (2003) stated that “the doctrine of vicarious liability is a common-law doctrine in which an employee has been negligent in the course and scope of employment; the employer will be made liable, if the patient suffers damage as a result” (p-85).

    According to Ellis & Hartley (2001) stated that “the law will hold the employer responsible in employing qualified persons and establishing an environment for correction functioning and providing supervision as required as to avoid errors or harm” (p-40). The hospital should ensure that all their policies and procedures manuals should be updated and relevant to the medical and nursing standard of practice within the institution. Nurses/midwives demonstrate professional conduct and practice in accordance with the standards of nursing practice determined by the regulatory board and accept that the primary duty is to ensure safe, and ethical nursing care to the client” (Singapore Nursing Board (2011), Standard 2). All medical and nursing staff should responsible to be familiar with the organisation’s policies and procedures where you work because this can protect you against a malpractice claim when you follow them carefully (Kothare, 2000).

    Unfortunately, both doctors and nurses failed to follow the protocols of administration medications set within the organization and stay abreast in the standard of care while performing their duty. Both nurses were failed to evaluate the care provided that was identified as negligence in which medication error had occur resulting Mr Lim to suffer cardiac arrest and brain damage. Nevertheless, this does not mean that the personal liability of the individual is transferred to the employer but that the responsibility for the negligent act is directed to the employer (Staunton & Chiarella, 2003).

    If the family members of Mr Lim wanted to sue the hospital, it would be liable for malpractice since both nurses and doctors were the employees of the hospital. They failed to act as reasonable and prudent their professional. Therefore, the hospital was liable since they failed to check on their staff’s competency in following the guidelines. Staff Nurse Su and May had breached the duty of care as the care provided fell below the standard of what a reasonable nurse would do. As a professional, nurses are accountable in providing a safe and competent care to their clients in a responsible and accountable manner.

    According to Staunton & Chiarella (2003) state that registered nurses are to have specific knowledge and expertise in relation to drugs, that knowledge and expertise should cause nurses to question the drug orders carefully in certain situations rather than blindly follow instructions. However, both nurses breached the duty of care in following the standard of nursing care which requires nurses to understand the medications they administering and used their judgments on following medication orders.

    As the Staff nurse in-charge of Mr Lim, Nurse Su would “be personally accountable in providing safe, competent and ethical care to their patients” (Singapore Nursing Board 2011, standard 2). She should be able to use her knowledge gained through education and clinical practice for safe and effective nursing care that “to promote client’s well-being and to protect clients by recognising and reporting unsafe practice” (Singapore Nursing Board 2011, standard 2). Unfortunately, Nurse Su failed to perform according to the standard required of qualified staff nurse who was working in the medical ward.

    When Nurse Su saw the orders, she questioned Dr Peter about the orders as a nurse have the right to question the drug orders with the prescribing physician when she/he in doubt of the orders or incorrect. However, Nurse Su should not connect up the infusion after Dr Peter verbalised that he had checked it with Dr Lee. As a professional nurse, she should not be content just asking Dr Peter when in doubt about the orders. She should ask Dr Peter that the order is meant for elderly patient and remind him that patient is chronic heart failure.

    Nurse Su should check with her colleague who is more experienced or escalate up check it with the consultant in-charge of Mr Lim, or pharmacist regarding the orders. Could Dr Peter be lying on even checking with Dr Lee or what are the medical experiences of Dr Lee? All these doubts should be lingering on Nurse Su’s mind. All this information should be documented clearly, accurate, legible and concise as documentation in the medical record was fundamental to safe patient care. It serves as a strategic part of each of every nursing action which was inseparable from the actual nursing care rendered (Beckmann, 1996).

    Nurse May as her colleague, she failed “to provide care in responsible and accountable manner” (Singapore Nursing Board 2011, standard 2) when countersign to serve medications. Did she really check the IV solution when she countersigns the medication record? Did she query Nurse Su or Dr Peter regarding the orders? Nurse May could take the initiative to question Dr Peter that the order was wrong, if she has any doubt in her mind as a professional nurse was not expected to make medication errors.

    This showed that Nurse May failed “to protect the clients well-being by recognising and reporting the unsafe practice or unable to provide safe, competent and ethical care to clients” (Singapore Nursing Board 2011, standard 2). Next, Nurse Su and May failed to check the adverse reaction of IV dextrose 50% on elderly patients. Hyper-osmolar syndrome can develop as a result of excessively rapid administration of concentrated dextrose may cause hypo-volemia, dehydration, mental confusion and loss of consciousness (Dextrose, 2007).

    From the above scenario, it showed that the nurses did not monitor serum glucose concentrations level of Mr Lim and monitor his vital sign frequently when receiving the IV infusion resulting in Mr Lim suffering from cardiac arrest and brain damaged. This showed that both staff nurses has pharmacological deficit as caution should be exercised with elderly receiving IV dextrose 50% as they are susceptible to glucose intolerance and hyperglycemia (Dextrose,2007).

    Medication error defines as “mistakes associated with drugs and intravenous solutions that are made during the prescription, transcription, dispensing, and administration phases of drug preparation and distribution” (Wolf, 1989, p-8). Medication error can be classified as either acts of commission or omission such as wrong drug, wrong dose, wrong route, wrong patient, wrong timing of drug administration, and a contra-indicated drug for the patient, wrong site, wrong drug form, wrong infusion rate, expired medication date, or prescription error.

    Such errors can occur in either an intentional or unintentional manner (Wolf, 1989). Unfortunately, Dr Peter has prescribed wrong medication instead of Dextrose 5%, he has ordered Dextrose 50%. Both Staff Nurses Su and May was administrated the wrong medication to Mr Lim due to lack of medication knowledge and negligence. Mr Lim’s family member are now more prepared to complain or take legal action for the harm that is caused cardiac arrest and suffering brain damage experienced as a consequence of medication error.

    Conclusion If both Staff Nurses Su and May were to think that patient’s safety was always a focus and able to act accordingly to what a reasonable nurses should do, all these unnecessary actions could be avoidable; thus, Mr Lim would not suffer any harm and no need to stay in hospital much longer than necessary. Wallace (1996) mentioned damage suffered by plaintiff can be physical, financial, and psychological or emotional damage.

    Therefore, the damage suffered by Mr Lim would be physical damage but his family could suffer from financial damage due to Mr Lim’s long term hospitalisation expenses and psychological damage from the experience that they had encountered. Hence, Mr Lim’s family member could claim compensation under specific damages which quantifies in monetary amounts such as Mr Lim’s cost of his medical treatment (Staunton & Chiarella, 2003). The case scenario has highlighted that medication error due to negligence or malpractice is an important part of delivering safe patient care.

    It would be leading to the legal issue occur when a health care professional malpractice or negligence. Instead of deliver high quality care to patient, errors occur on both a systems and personal level. The above scenario has occurred medication error due to both doctor’s and nurse’s lack of personal level knowledge in medication. in consequence, from the above scenario Dr Peter, Dr Lee, both staff nurses Su and May would be found liable for their actions; causing harms to Mr Lim. A disciplinary action would be imposed to both doctors and both nurses by their head department for their professional misconduct. Both doctors would be referring to the medical board for further disciplinary action and both staff nurses would be referring to the Nursing board for further disciplinary action.


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