Legal and Ethical Issues in
Maternal/Newborn and
Women’s Health
Developed by
D. Ann Currie , R.N. , M.S.N.
LEGAL CONSIDERATIONS
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GENERAL LEGAL CONCEPTS
ARENAS FOR CONSIDERATION
LITIGATION
RISK MANAGEMENT
QUALITY ASSURANCE
DOCUMENTATION
CLINCAL EXAMPLES OF COMMON LEGAL
ISSUES
GENERAL LEGAL CONCEPTS
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LAW CAN BE DEFINED AS”THOSE RULES
MADE BY HUMANS WHICH REGULATE
SOCIAL CONDUCT IN A FORMALLY
PRESCRIBED AND LEGALLY BINDING
MANNER.”(BERNZWEIG)
FUNCTIONS OF THE LAW IN
NURSING
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THE LAW SERVES A NUMBER OF
FUNCTIONS IN NURSING:
IT PROVIDES A FRAMEWORK FOR
ESTABLISHING WHICH NURSING
ACTIONS IN THE CARE OF THE CLIENTS
ARE LEGAL
IT DIFFERENTIATES THE
NURSE’SRESPONSIBILITIES FROM THOSE
OF OTHER HEALTH PROFESSIONAL
CONT. FUNCTIONS
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IT HELPS ESTABLISH THE BOUNDARIES
OF INDEPENDENT NURSING ACTION.
IT ASSISTS IN MAINTAINING A
STANDARD OF NURSING PRACTICE BY
MAKING NURSES ACCOUNTABLE UNDER
THE LAW.
SOURCES OF LAW
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CONSTITUTION
LEGISLATION (STATUTES)
COMMON LAW
TYPES OF LAWS
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PUBLIC LAW- CRIMINAL LAW
PRIVATE LAW-CIVIL LAW
CONTRACT LAW
TORT LAW
ARENAS OF LEGAL
CONSIDERATION
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PERSONAL PROFESSIONAL PRACTICE
CLIENT CARE AND ADVOCACY
LEGAL CONSIDERATIONS IN
PERSONAL PROFESSIONAL
PRACTICE
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SCOPE OF PRACTICE
STANDARDS OF CARE
LICENSURE
COLLECTIVE BARGAINING
SCOPE OF PRACTICE
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THE NURSE PRACTICE ACT---BROAD DEFINITION OF PERMISSIBLE
BOUNDARIES OF PRACTICE WITHIN A
STATE.
DISTINGUISHES NURSING PRACTICE
FROM THE PRACTICE OF OTHER HEALTH
PROFESSIONALS
SCOPE OF PRACTICE
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EXCLUDES UNTRAINED OR UNLICENSED
INDIVIDUALS FROM PRACTICING
NURSING.
RULES AND REGULATIONS
PROMULGATED BY STATE BOARDS OF
NURSING PROVIDE OFFICIAL
INTERPRETATION OF NURSING ACTS.
SCOPE OF PRACTICE
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CORRECT INTERPRETATION AND
UNDERSTANDING OF STATE PRACTICE
ACTS ENABLES THE NURSE: TO PROVIDE
SAFE CARE WITHIN THE LIMITS OF
NURSING PRACTICE AND TO AVOID THE
RISK OF BEING ACCUSED OF PRACTICING
MEDICINE WITHOUT A LICENSE
READ AND KNOW THE NURSE PRACTICE
ACT ****.
STANDARDS OF CARE
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DEFINITION:
MINIMUM CRITERIA FOR
COMPETENT,PROFICIENT DELIVERY OF
NURSING CARE.
USED TO EVALUATE THE QUALITY OF
CARE PROVIDED
FORMULATED FROM SKILLS AND
KNOWLEDGE COMMONLY POSSESSED BY
MEMBERS OF
CONT.
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A PROFESSION….NURSES.
IDENTIFY
HEALTH,DEMOGRAPHIC,ENIRONMENTAL,
AND PSYCHOSOCIAL PARAMETERS OF
CARE
REFLECTS CURRENT KNOWLEDGE IN THE
FIELD,AND,THEREFORE,ARE DYNAMIC
AND SUBJECT TO CHANGE.
USES OF STANDARDS OF
CARE
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CRITERION FOR DETERMINING IF A
NURSE HAS VIOLATED THE STATE NURSE PRACTICE ACT.
CRITERION FOR DETERMINING IF A
NURSE HAS VIOLATED STATE OR CITY
CRIMINAL CODES
CRITERION ELEVATING NURSING
PRACTICE TO A PROFESSIONAL LEVEL.
INTERNAL STANDARDS OF
CARE
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INDIVDUAL
INSTITUTIONAL
SET BY ROLE AND EDUCATION OF THE
NURSE: JOB
DESCRIPTION,EDUCATION,AND
EXPERTISE
SET BY INDIVIDUAL INSTITUTIONS:
POLICIES AND PROCEDURES.
EXTERNAL OR NATIONAL
STANDARDS OF CARE
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EXTERNAL BECAUSE THEY SUPERCEDE
INDIVIDUAL PRACTITIONERS AND
INSTITUTIONS.
BROADER THAN LOCALITY RULES:
STANDARDS OF CARE VEIWED FROM THE
PERSPECTIVE OF CARE WITHIN A
GEOGRAPHIC AREA.
CONT. EXTERNAL
STANDARDS OF CARE
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BASED ON REASONABLENESS AND
AVERAGE DEGREE OF SKILL,CARE, AND
DILIGENCE PRACTICED BY MEMBERS OF
THE PROFESSION ACROSS THE NATION.
NURSES IN A VARIETY OF SETTINGS AND
LOCALS MUST MEET THE SAME
STANDARDS: HOMES,BIRTHING
CENTERS,HOSPITALS ETC.
CONT. ETERNAL
STANDARDS OF CARE
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STANDARDS ESTABLISHED BY:
STATE BOARDS OF NURSING THROUGH
NURSE PRACTCE ACTS OR
PROMULGATED RULES AND
REGULATIONS.
PROFESSIOAL ORGANIZATIONS:
ANA,ICN,OR CONGRESS FOR NURSING
PRACTICE.
CONT. EXTERNAL
STANDARDS OF CARE
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SPECIALITY NURSING
ORGANIZATIONS:AWHONN,NANN, ACNM.
FEDERAL ORGANIZATIONS AND
GUIDELINE: JCAHO AND MEDICARE
RULES.
STANDARD OF CARE
NEGLIGENCE AND
MALPRACTICE
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NEGLIGENCE- IT IS OMITTING AN ACT
OR DEVIATION FROM THE STANDARD OF
CARE THAT A REASONABLY PRUDENT
PERSON WOULD NOT OMIT OR COMMIT
UNDER SIMILAR CIRCUMSTANCES.
MALPRACTICE- IT IS A NEGLIGENT
ACTION OF A PROFESSIONAL
ELEMENTS OF NEGLIGENCE
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THERE WAS A DUTY TO PROVIDE CARE.
THE DUTY WAS BREACHED.
INJURY OCCURRED.
THE BREACH OF DUTY CAUSED INJURY
EXAMPLES OF NEGLIGENCE
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EXAMPLES OF OMISSION: FAILING TO
GIVE A MEDICATION, FAILING TO
ASSESS PROPERLY,FAILING TO NOTIFY A
PHYSICIAN OF A CHANGE IN A CLIENT”S
CONDITION OR STAUS.
EXAMPLES OF COMMISSION:GIVING
WRONG MEDICATION OR TO WRONG
CLIENT
CONT.
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PLACING INFANT IN WRONG CRIB OR
GIVING INFANT TO WRONG MOTHER.
CONT.
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NURSES NOT MEETING APPROPRIATE
STANDARDS OF CARE COULD BE
SUBJECT TO ALEGATIONS OF
NEGLIGENCE OR MALPRACTICE.
NURSE’S RESPONSILITY IN
PREVENTING NEGLIGENCE
AND MALPRACTICE
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OBTAIN AND MAINTAIN CURRENT
INFORMATION REGARDING THE STATE
NURSE PRACTICE ACT- GET A COPY AND
READ IT AND KNOW IT..READ
PUBLICATION FROM THE STATE (BON),
VISIT WEB SITE FOR BNE INFORMATION
AND ATTEND BNE WORKSHOPS.
CONT. NURSE
RESPONSIBLITY
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OBTAIN AND MAINTAIN CURRENT
INFORMATION ON INTERNAL AND
EXTERNAL STANDARDS OF PRACTICE,
SEEK CONTINUING EDUCATION TO
REMAIN CURRENT IN SPECALITY AREAS
USE THE NURSING PROCESS WHEN
GIVING CLIENT CARE.
CONT. NURSE’S
RESPONSIBILITY
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DEVELOPE A POSITIVE, EMPOWERING
RELATIONSHIP WITH CLIENTS---SEE
CLIENTS AS AN IMPORTANT MEMBER OF
THE HEALTH TEAM.
BE THROUGH IN COMPLETING AND
REPORTING ASSESSMENTS AND
IMPLEMENTING CARE.
CONT NURSE’S
RESPONSIBLITY
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MAINTAIN CLEAR, CONCISE, ACCURATE,
COMPLETE, AND LEDGIBLE
DOCUMENTATION.
QUESTION APPROPRIATENESS OF CARE
WHEN HARM CAN BE DONE TO CLIENT.
CHECK MEDICAL ORDERS FREQUENTLY.
USE CHAIN OF COMMAND.
LEGAL CONSIDERATIONS
FOR CLIENT CARE
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HEALTHCARE REFORM
MANAGED CARE
SHORTENED HOSPITAL STAYS
UNLICENSED ASSISTIVE
PERSONNNEL(UAP)
NURSE’S ROLE AS CLIENT ADVOCATE.
Healthcare reform
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The USA leads the world in healthcare
spending, yet has one of the highest
infant mortality rates among the
industrialized nations……..
One of the primary factors related to
infant mortality(deaths under one year of
age per 1000 live births) is an increase in
the delivery of low birth weight infants,
which is linked to lack of prenatal care.
Healthcare Reform
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Barriers to access to prenatal care
1) Costs of health care
2) Limited financial resources
3)Uncoordinated service systems
4) Individual behaviors and beliefs
concerning health care
5)Bureaucratic obstacles, such as
complicated, lengthy forms for
Medicaid
HEALTHCARE REFORM
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Barriers to prenatal care
6) Unavailability of maternal services in
certain parts of the country
7) Underfunded and overcrowded publicly
supervised clinics
8) Difficulty in recruiting and retaining
healthcare providers in publicly subsidized
clinics
Healthcare reform
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Barriers to prenatal care
9) Lack of coordinated services for needy
individuals
10) Inaccessibility to prenatal services
because of transportation, location, and
lack of child care facilities.
11) Other….
HEALTHCARE REFORM
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Federal and state governments, through
policies and legislation, have begun to
implement strategies to resolve these
barriers by:
1) Broadening health insurance coverage
for childbearing women and infants
2) Improving coordination and funding of
public programs
Healthcare Reforms
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3) Simplifying bureaucratic procedures
4) Increasing the number of maternity
care providers
5) Establishing a national council on
children and health
6) Raising public awareness throughout
the country
7) Other…..
HEALTHCARE REFORM
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NEED TO CONTINUE to seek reform to
further control costs, improve access to
healthcare, and improve quality of
healthcare
MANAGED CARE
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Private sector solution for decreasing
healthcare costs
1) Health insurance plans that combine:
delivery of healthcare services, financing
of those services, controlling the use of
services.
2) Philosophy of managed care
organizations includes:
Managed Care
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Cont. Health promotion and disease
prevention, desire to avoid serious disease
and costly treatment services
3)To meet expenses and make a
reasonable profits
4) Creates a climate in which providers
have: little time and few resources with
which to provide care and financial
MANAGED CARE
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CONT. -DISINCENTIVES FOR PROVIDERS
TO GIVE ADEQUATE SERVICES TO THEIR
CLIENTS.
5) CONSEQUENCES : FEWER EXPENSIVE
TESTS OR COSTLY PROCEDURS
PERFORMED, SHORTENED HOSPITAL
STAYS AND INCREASED USE OF
UNLICENSED HEALTHCARE WORKERS.
SHORTENED HOSPITAL
STAYS
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During the early to mid-1990 hospital
stays after birth were shortened to 24
hours or less….
Consequently, there was not enough time
for maternal and parental teaching
regarding self care and infant careproblems in infant care and health
developed, breast-feeding problems, and
self care problems in the mothers.
SHORTENED HOSPITAL
STAYS
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Several states passed laws requiring
longer stays for maternity and neonatal
clients..
U.S. Congress passed Senate Bill 969, the
Newborns’ and Mothers’ Protection Act of
1996:1) Set a national standard requiring
health insurance and employer-provided
benefit plans to cover minimum hospital
stay: 48hrs-vaginal delivery,
SHORTENED HOSPITAL
STAYS
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96 hrs for c/s, early discharge with home
health care..within 24-72 hrs of discharge.
2) Even with federal law mandating a
longer postpartum stay, nurses are still
responsible for: verbal and written
instructions about infant and self-care,
and s/s indicating problems and what to
do, and f/u visit.
In Texas nurses must teach about PP
depression
SHORTENED HOSPITAL
STAYS
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Cont. evaluation of parents’ learning,
recommending timely follow-up care,
incliding a home visit,whenmom seems at
risk after a longer stay.
UNLICENSED ASSISTIVE
PERSONNEL (UAP)
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UAPs are healthcare workers who have no
defined body of knowledge or educational
preparation upon which to base their
practice
Uncreditentialed
No state or federal regulatory body to
validate their competence
UAPS
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Nurses are responsible for the delegation
of tasks to UAPs…see Texas BON
guidelines for delegation .
UAPs can perform repetitive tasks…which
are clearly defined and for which they
have been trained.
Nurses should obtain information on UAPs’
training and skills prior to delegating
tasks.
UAPS
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Inappropriate delegation to UAPs
increases the nurse’s liability and may
jeopardize the nurse’s license.
What should not be delegated to UAPs:
Essential nursing processes of
assessing,diagnosing of a problem,
planning client care, implementing that
care, and evaluating the outcomes.And
judgements about client status.
NURSE’S ROLE AS CLIENT
ADVOCATE
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Maintain current information about issues
critical to client care….
Educate clients and other significant
persons about such issues…
Become involved in the political process as
an advocate for quality healthcare for all
healthcare recipients.
Other…...
LITIGATION
RISK MANGEMENT
QUALITY ASSURANCE
DOCUMENTATION
CLINICAL EXAMPLES OF
COMMON LEGAL ISSUES
ETHICAL CONSIDERATIONS
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ETHICS IS BASED ON A RESPONSIBILITY
OR DUTY MODEL EXAMINING WHAT OUR
BEHAVIOR OUGHT TO BE IN RELATION
TO OURSELVES, OTHER HUMAN
BEINGS,AND THE ENVIRONMENT
ETHICS
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ETHICS INCORPORATES FACTORS SUCH
AS: RISKS.BENEFITS,OTHER
RELATIONSHIPS, CONCERNS, AND THE
NEEDS AND ABILITIES OF PERSONS
AFFECTED BY AND AFFECTING
DECISIONS.
IT IS SUBJECT TO PHILOSOPHICAL,
MORAL, AND INDIVIDUAL
INTERPRETATIONS.
ETHICAL PRINCIPLES
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SHOULD BE USE IN CLINICAL PRACTICE
RESPECT
AUTONOMY
BENEFICENCE
NONMALEFICENCE
VERACITY: DUTY TO TELL THE TRUTH
CONT. ETHICAL PRINCIPLES
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FIDELITY: DUTY TO KEEP ONE’S
PROMISE
JUSTICE
CONFIDENTIALITY
INFORMED CONSENT
UNIVERSALITY
ETHICAL DECISION-MAKING
FRAMEWORK
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MORAL
M:ESSAGE THE DILEMMA
O:OUTLINE THE OPTIONS
R:RESOLVE THE DILEMMA
A:ACT BY APPLYING THE CHOSEN
OPTION
L:LOOK BACK AND EVALUATE THE
ENTIRE PROCESS
MORAL
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M: MESSAGE THE DILEMMA
IDENTIFY AND DEFINE ISSUES IN THE
DILEMMA
DETERMINE WHO OWNS THE
PROBLEM,THE INFORMATION,THE
DECISION, AND THE CONSEQUENCES OF
IT.
CONT. M
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ESTABLISH THE FACTS AS BEST AS
POSSIBLE.
CONSIDER THE OPTIONS,VALUES, AND
MORAL POSITION OF THE MAJOR
PLAYERS.
IDENTIFY VALUE CONFLICTS.
O: OUTLINE THE OPTIONS
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EXAMINE ALL OPTIONS
FULLY,INCLUDING THE LESS REALISTIC
AND CONFLICTING ONES
IDENTIFY PROS AND CONS OF ALL THE
OPTIONS
FULLY COMPREHEND THE OPTIONS AND
ALTERATIVES AVAILABLE/
R: RESOLVE THE DILEMMA
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REVIEW THE ISSUES AND OPTIONS
APPLY ETHICAL PRINCIPLES TO EACH
OPTION
DECIDE THE BEST OPTION FOR ACTION
ON THE VIEWS OF ALL THOSE
CONCERNED
A: ACT BY APPLYING THE
CHOSEN OPTION
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IMPLEMENT THE CHOSEN OPTION
L: LOOK BACK AND
EVALUATE THE ENTIRE
PROCESS
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INCLUDING IMPLEMENTATION.
ENSURE THAT ALL THOSE INVOLVED ARE
ABLE TO FOLLOW THROUGH ON THE
FINAL OPTION
REVISE THE DECISION AS
INDICATED,STARTING THE PROCESS
WITH THE INITIAL STEP.
WHERE TO GET HELP TO
MAKE AN ETHICAL DECISION.
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Ethics committee in your
organization…hospital.
Clergy
Ethics depart.
Text...
ETHICAL CONSIDERATIONS
IN MATERNITY NURSING
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ASSISTED REPRODUCTION
ABORTION
FETAL OR EMBRYO RESEACH
CORD BLOOD BANKING
THE HUMAN GENOME PROJECT
GENETIC COUNSELING
FETAL RIGHTS VERSUS MATERNAL
RIGHTS
NURSES’
RESPONSPONSIBLITIES
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Learn to anticipate ethical dilemmas
Identify attitudes,values, and beliefs about
ethical dilemmas taking into consideration
the influence of cultural,religious, and
social factors on the development of
values.
Recognize the influence personal values
have on care provided for clients by
engaging in self-values clarification
activities.
NURSES’RESPONSIBILTIES
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Review and update theoretical bases:
gather current information on
technological advances and changing
trends in maternity nursing, review ethical
principles and practice codes in regard to
new technology and trends, become
familiar with the client’s knowledge base
by reading lay literature related to
maternity and neonatal advances
NURSES’ RESPONSIBILTIES
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Attend cont. ed. Programs related to
ethical issues and decision making-participate in ethics committees with other
healthcare professionals and inservice
peers on ethical issues and decision
making.
Review research journals regarding
current trends in ethical decision making
.comparing and contrasting the results
with what is occurring in the clinical
NURSES’ RESPONSIBILITES
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Evaluate current social norms by following
social,legal,religious, and political debates
that may influence clinical decision making
and quality care for clients experiencing
dilemmas in the maternal, neontal, or
women’s health areas.
Avoid judgements about the life decisions
of others.
NURSES’S
RESPONSIBILITIES
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Aim to accept the values of others and
their decisions regarding issues and
provisions of care.
Don’t allow personal beliefs and values to
interfere with provision of quality care.
Understand the legal implications of the
issues
Develop appropriate strategies for ethical
decision making.