Mr.Channabasappa.K.

M PCON

UNIT 12: LEGAL AND ETHICAL ISSUES LAWS AND ETHICS

1.LAWS AND ETHICS, ETHICAL COMMITTEE, CODE OF ETHICS AND PROFESSIONAL CONDUCT, LAGAL SYSTEM: - TYPES OF LAWS, TORT LAW, AND LIABILITIES. INTRODUCTION From we were very young we began to learn what was right and what wrong behavior was. We learned this from our parents, relatives, friends and teachers. By the time we became adults, we had a personal set of ethics to guide our behavior in daily life. We may believe, for example, that honesty is important and necessary and important. We will try to be honest because we believe it is right to do so. Being dishonest would then be wrong for us. This is ethical behavior. TERMINOLOGIES Competent: adequately qualified. Judicious: sensible; prudent Conducive: leading to some end Collaborate: work in combination Conscience: moral sense of right and wrong Contemporary: living or occurring at same time Deterrent: frightening or hindering Submissive: surrendering: obedient

ETHICS
Definition Ethics refers to the moral code for nursing and is based on obligation to service and respect for human life. Melanie and Evelyn. Ethics are the rules or principles that govern right conduct and are designed to protect the rights of human beings. Sister Nancy. CODE OF ETHICS Definition; 1. A code of ethics is a set of ethical principles that are accepted by all members of a profession. Potter and Perry 2 Code of ethics is a guideline for performance and standards and personal responsibility. 1

Lillie M S and Juanita Lee 3. Code of ethics provides a frame work for decision making for the profession and should be oriented toward the day to day decisions made by members of the profession. Chitty K K 4. A code of ethics is a set of ethical principle that A} is shared by members of a group B} reflects their moral judgments over time C} serves as a standard for their professional actions. Barbara Kozier

Nursing Ethics Its a branch of applied ethics that concerns itself with activities in the field of nursing. Its refers to ethical standards that govern and guide nurses in every day practice such as being truthful with clients , respecting client confidentiality, and advocating on behalf of the client.

Need for nursing ethics Helps the students/ RN to practice ethically Helps the nurse to identify the ethical issues in her work place Protecting patients right and dignity Providing care with possible risk to the nurses health Staffing patterns that limit the patients access to nursing care Ethical reasoning Helps the nurse to respond to ethical conflicts Helps to differentiate right /wrong behavior Guide for a professional behavior Help teachers plan education. Prevent below standard practice. Protect a nurse if falsely accused and guide direction for legal action

Key Principles of ethics in health care system 2

Mr.Channabasappa.K.M PCON

Autonomy-The right of self determination, independence and freedom. Right to health care decision. Justice-Obligation to be fair with all people. Fidelity- Obligation of an individual to be faithful to the commitment made to himself, and to others. It is the main support of accountability. Veracity: - The duty to tell the truth. Beneficence- Doing good for the client. What exactly is good for one person may not be the same for others. Malaeficence- is the requirement that health care providers do no harm to their client either intentionally or unintentionally Deontological:-What causes a good outcome is good action. Situational: - What causes a good outcome is good action. Thus a professions ethical code is a collective statement about the groups expectations and standards of behavior. The ANA and ICN have established widely accepted codes that professional nurses attempt to follow. DEFINITION:Ethics:Ethics is the study of good conduct, character and motives. It is concerned with determining what is good or valuable for all people. Act that are ethical often reflect a commitment to standards beyond personal preference standards on which individuals, professions and societies agree. Code of ethics:Code of ethics is the providing guidelines for safe and compassionate care. Nurses commitment to a code of ethics guarantees the public that nurses adhere to professional practice standards. CODE OF ETHICS Within any given profession, a code of ethics serves as a means of self-regulation and a source of guidelines for individual behaviour and responsibility.

I.C.N CODE OF ETHICS FOR NURSES(1993) Ethical concepts applied to nursing:The fundamental responsibility of the nurses is of four fold: to promote health, to prevent illness, to restore health and to alleviate suffering. Elements of the code:Nurses and people The nurses primary responsibility is the those people who require nursing care The nurses provides care, promotes an environment in which the values customs and spiritual beliefs of the individual are respected The nurses holds confidence, personal information and uses judgment in sharing their information

Nurses and practice The nurse carries personal responsibility for nursing practice and for maintaining competence by continuous learning The nurses maintains the higher standards of nursing care possible within the reality of a specific situation The nurses assess judgment in relation to individual competence when accepting and delegating responsibilities The nurse when acting in a professional capacity should at all times maintain standards of personal conduct which reflect created upon the profession

Nurses and Society The nurses with other citizens the responsibility for initiating and supporting action to in edit the health and social needs of the public Nurses and Co-workers The nurse sustains a co-operative relationship with co-workers in practice and nursing education The nurse is active in developing a care of professional knowledge The nurse acting through the professional organization, participants in establishing and maintaining equitable social and economic working conditions in nursing. nursing

Mr.Channabasappa.K.M PCON AMERICAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSES The nurses in all professional relationships practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations if should or economic status personal attributes or the nature of health problems. The nurses primary commitment is to patient, whether an individual, family, group or community. The nurses promote, advocates for the strives to protect the health, safety and rights of the patient. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care. The nurse owns the same duties to self as others including the responsibility to preserve integrity and safety to maintain competence and to continue personal and professional growth. The nurses participates in establishing, maintaining and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. The nurses participates in the advancement of eh profession through contribution to practice, education, administration and knowledge development. The nurses collaborates with others health professional and the public in promoting community, national and international efforts to met the health needs. The profession of nursing as represents by associations and their members, is responsible for articulating nursing values for maintaining the integral of the profession and its practice for shaping the social policy.

CANADIAN NURSES ASSOCIATION CODE OF ETHICS FOR NURSING Health and Well being: Nurses value health and well being and assist persons to achieve their optimum level of health in situations of normal health illness, injury or in the process of dying. Choice : Nurses respect and promote the autonomy of clients and them to express their health needs and values and to obtain the appropriate information and services Dignity : Nurse value and advocate the dignity and self-respect of human beings Confidentiality: Nurses safeguard the trust of clients that information learned in the context of a professional relationship is spread outside the health care team only with the clients mission or as legally required.

 Fairness : Nurses apply and promote principles of equity and fairness to assist clients in receiving inhibited treatment and a share of health services and resource proportionate to their needs Accountability : Nurses act on a manner consistent with their professional responsibilities and standards of practices Practice Environment: Conducive to safe, competent and ethical care. Nurses advocate the practice environments that have the organizational and human support systems and the resource allocation necessary for safe, competent and ethical nursing care.

TYPE OF ETHICAL THEORIES 1. Duty-oriented ethical theories A duty oriented ethical theory is a system of ethical thinking having the concept of duty or obligation as foundation. Duties are strict obligations that take primary over rights and goals. Keep in mind however each duty has corresponding rights. Duty-oriented theories are advantages in homogeneous societies in which each person hold the service values. A duty oriented theory would work well in a tribal society because it is easier to share values and therefore beliefs among a small group of people. A disadvantage of a duty-oriented theory is determining how to rank duties. For example, a nurse may be form between a duty to support life and a duty to prevent suffering. 2. Rights-Oriented Ethical theories A rights-oriented ethical theory is a system of ethical thinking having the concept of rights as a foundation. Rights-oriented theories assign the highest value to rights, so that duties and goals flow from rights, from right oriented perspective, your would first look to the clients right to privacy flowing from that right to privacy would be your duty to keep care information confidential to achieve the goal of encouraging clients to communicate information freely.

Duty Oriented Ethical Theories Duties

Rights Oriented Ethical Theories Right

Right

Duties

Goals 3. Goal-oriented ethical theories

Goals

Mr.Channabasappa.K.M PCON A goal-oriented ethical theory is a system of ethical thinking having the concept of maximizing the overall goal as its foundation- goal-related theories suggest that good choices result from concern with the consequences of actions In todays environment of health care reform nurses might choose to support changes that will provide basic preventive and treatment services for all. Providing both prevention and treatment could be viewed as maximizing the welfare of society Goal-Orienetd Ethical Theories Goals

Duties

Rights

4. Intuitionist ethical theory An ethical theory is a system of ethical thinking that balances goals, rights and duties according to the situation. Philosophers espousing this theory argue that humans innately know good from bad and that through intuition, duties, goals and rights can be balanced.

Intuitionist Ethical Theories

Duties

Goals

Rights

ETHICAL PRINCIPLES Ethical principles actually control professionalism nursing practice much more than to ethical theories. Principles are the moral norms that nursing, as a profession, both demands and strives to implement to every day clinical practice. Ethical principles that the nurses should consider when making decisions are as follows 1. Respect for persons 2. Respect for autonomy 3. Respect for freedom 4. Respect for beneficence (doing good) 5. Respect for non-malfeasance(avoiding harm to others)

6. Respect for veracity ( truth telling) 7. Respect for justice ( fair and equal treatment) 8. Respect for rights 9. Respect for fidelity ( fulfilling promises) 10. confidentiality ( protecting privileged information )

1. Respect for persons This principle not only applied to clinical situation, but it applies to all life situations it directs individuals to treat themselves and other with a respect inherent to main humans. The respect to persons a need to be simplified as not affects nursing practice. 2. Autonomy Autonomy means that individuals are able to act for themselves to the level of their capacity. It is the rights of individuals, governing their actions according to their own purpose and reason. 3. Freedom Nurses a group believes that patient should be observed freedom of choice within the nations health care system. This principle should be observed by staff nurses when planning patient care, by nurses manager when leading subordinates 4. Beneficence: (the ethical principles of upholding doing good) The beneficence principles states that the actions one takes should promote good. It requires the balancing the harms and benefits. Benefits promote the clients welfare and health whereas harms or risks detract from the clients health and welfare. In other words, providing benefits that enhance the other welfare. Whereas balancing the benefits and harms of intervention made on the others half. 5. Non- Maleficence The principle of non- maleficence states that one should do no harm. The nurses should interpret the term harm to mean emotional and social as well as physical injury. Harm is threading, defeating or setting back one person./s interest through invasive action by another. 6. Veracity Veracity concerns truth talking and incorporates the concept that individuals should always tell the truth. It requires professional care givers to provide with accurate, reality based information about their health status and care or treatment prospective. 7. Justice Justice concerns the issue that persons should be treated equally and fairly. This principle of justice requires treating others fairly and giving persons their due.

Mr.Channabasappa.K.M PCON 8. Rights Rights is an entitlement to behave in a certain way under circumstances, such as nurses entitlement to freely express personal beliefs and preferences by voting in a political election. Right is also used to mean agreement with justice, law and morality. So right may be mental rights or legal rights to respective profession. 9. Fidelity Fidelity is keeping ones promises or committeemens. The principles of fidelity hold that a person should faithfully fulfill his duties and obligations. 10. Confidentiality Confidentiality is the duty to respect privileged information. The principle of confidentiality provides that care-givers should respect a patient need for privacy and by personal information about him or her only to improve care. Nurses should practice confidentiality to decrease patient vulnerability and share from widespread knowledge of personal information divulged during care.

ETHICAL DILEMMAS A dilemma is defined as a situation requiring a choice between two equally desirable or undesirable alternatives. In ethical dilemma each alternative course of action can be justified by two ways in which a person views the course of action based on his or her value system. Increasingly, staff nurses and nurse managers face difficult decisions caused by tensions between technological capabilities, budgetary strictures, and quality of life concerns.

Nurses in all clinical and functional specialties face the following dilemmas. Need to ration patient care to conserve scarce resources Need to make treatment and care of decisions for terminally ill patients Need to obtain patients informed consent for care treatment orders and measures such as o Do not requisite order o With holding/with drawing nutrition and fluids o Starting / discontinuing life support system Responses to patient request for assisted suicide Need to balance the patients need for confidentiality and privacy against societies needs for protection from unreasonable risk Need to protect autonomy rights of children and consent for rese4arch participation incompetent adults concerning

 Need to protect justice rights of patients who participate in random trails experimental treatment. Decision Making The nursing process is a system at the step-by step approach to resolving problems that deals with a clients health and well-being. The chief goal of the ethical decisions making process is to determine right and wrong in situation. The following ethical decision-making progress is presented or a tool for resolving ethical dilemma. Step I: Collect, Analyze and interpret the data Obtain as much information as possible concerning the particular ethical dilemma; unfortunately such information is sometimes very limited. The clients wishes the clients familys emotional problems carrying the dilemma, the physicians beliefs about health care and the nurses own orientation to concerning life and death Step II: State the Dilemma After collecting and analysis much information as available the nurses to state the dilemma as clearly as possible the step. It is important to identify whether the problem is one that can be resolved only by the client, clients family and the physician. Step III: Consider the choices of action After stating the dilemma as early as possible the next step as to attempt to help the considerations of their consequences all possible covering the action that can be taken to resolve the dilemma. Step IV: Analyze the advantage and disadvantages of each course of action Some of the courses of action developed during the previous step are more relates readily evident during this step in the decision making process when the advantages and the disadvantages of each action are considered in detail. Along with each action the consequences of taking each course of action must be thoroughly evaluated. Step V: Make the decision and act on it. The most difficult part of the process is actually making the decision following through with action and the living in the consequences. Decision are often made with no follow through because nurses are fearful the consequences of their decisions. Ethical Decision- making

of

Identify potential ethical dilemma

Collect analyze and interpret data

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Mr.Channabasappa.K.M PCON

State the dilemma

Dilemma cannot be Resolved by nurse

Dilemma can be resolved by nurse

Take no action

List potential solutions

Acceptable Consequences

Unacceptable consequences

Ethical decision

Take no action

Dilemma resolution

ROLES AND FUNCTIONS OF ADMINISTRATOR IN ETHICAL ISSUES The leadership roles and management functions of an administrator in ethics as follows He or she is self aware regarding own values and basic beliefs about the rights, duties and goals of human beings Accepts that some ambiguity and uncertainty be a part of all ethical decisionmaking Accepts that negative outcomes occur in ethical decision making despite high quality problem solving and decision-making Demonstrates risk taking in ethical decision making Role models ethical decision-making which are congruent with the code of ethics and inter respective statements Actively advocates for clients, subordinates and the profession Clearly communicates expected ethical standards of behavior Uses a systematic approach to problem-solving or decision making when faced with management problems with ethical ramifications Identify outcomes in ethical decision-making that should always be sought to avoided Uses establishment ethical framework to clarify values and benefits

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 Applies principles of ethical reasoning to define what beliefs or values from a basis of decision making It aware of legal procedures that may guide ethical decision making and is accountable for possible habitats should they go against the legal precedent. Continuously re-evaluate quality of won ethical decision making based on the present of decision making problem-solving used Recognizes and rewards ethical conduct of subordinates Takes appropriates actions when subordinates use unethical conduct

PROFESSIONAL CONDUCT Code of professional conduct (for nurses in India) 1. Professional responsibility and accountability To maintain professional responsibility and accountability, the nurse Appreciates a sense of self-worth and nurtures. Maintains standards of personal conduct, reflecting credit upon the profession. Carriers out responsibilities within the framework of the professional boundaries is accountable for maintaining practice standards set by the Indian Nursing Council. Is accountable for his/her own decisions and actions. Is compassionate. Is responsible for the continuous improvement of current practices Provides adequate information to individuals these allows them to make informed choices. Practices healthful behavior. 2. Nursing Practice In the course of practice of nursing, the nurse Provide care in accordance with set standards of practice Treats all individuals and families with human dignity in providing the physical, psychological, emotional , social and spiritual and aspects of care Respects individuals and families in the context of traditional and cultural practicing, promoting healthy practices and discouraging harmful practiced Presents realistic practices truthful in all situations for facilitating autonomous decisions making by individuals and families Promote participation and individuals and significant others in the care 12

Mr.Channabasappa.K.M PCON Ensures safe practice Consults, co-ordinates, callboards and follow p approximately when an individuals care needs exceed the his or her competence 3. Communication and interpersonal relationships This plays a key role in the interaction of the nurse with his or her clients. To effect optimal interaction the nurse Establishments and maintains effective interpersonal relationships with individuals families and communities Upholds the dignity of team members and maintains effective interpersonal relationship with them Appreciates a and nurtures the professional role of team members Co-operates with other health professionals to meet the needs of individuals , families and communities 4. Valuing human being The nurse values human life. He or she o Takes appropriate action to protect individuals from harmful unethical practices o Considers relevant facts while taking cons decisions in the best interest of individuals o Encourages and supports individual in heir right to speak for themselves on issues affecting health and welfare

o Respects and supports choices made by individuals.

5. Management Proper management of resources and unfortunate is essential for improving the over all efficiency of the nurse. Hence the nurses Ensures appropriate allocation and utilization of available responses Participates in supervision and education of students and other formal providers Uses judgment in relation to individual competence which accepting and delegating responsibility Facilitates conducive work culture in order to achieve institutional objectives Communicates effectively following appropriate channels if communication Participates in performance appraisal Participates in evaluation of nursing services Participates in policy decision, following the principles of equity and accessibility of service 13

 Works individuals to identify the needs and sensitizes policy makers and funding agencies for resource allocation Professional Advancement To escape that he or she is at part with contemporaries in the nursing field the nurse must. a. b. c. d. Ensures the protection of human rights, while pursuing the advancement of knowledge Participate in determine and implementing quality Take responsibility for updating ones own knowledge and competencies Contribute to the core of professional knowledge and conducting and participating in research

ICN CODE OF ETHICS FOR NURSES In 1953 ICN adopted its first code of ethics for nurses and was revised in 2000. The four principle elements contained within the ICN code involve standards related to nurses and people, practice, profession and co workers. ICN recommended that nurses have 4 fundamental responsibilities i.e. to promote health, to prevent illness, to restore health and to alleviating suffering. And also inherent in nursing is respect for human rights, like right to life, to dignity and to be treated with respect. And the care should not be restricted by age, sex, color, creed, culture or nationality.

Nurses and people The nurses primary responsibility is to those people who require nursing care. The nurse in providing care promotes an environment in the values, customs, and spiritual beliefs of the individual are respected .the nurse holds in confidence personal information and use judgement in sharing this information. Nurses and practice The nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning. The nurse maintains the highest standard of nursing care possible within the reality of a specific situation. The nurse uses judgement in relation to individual competence when accepting and delegating responsibilities. The nurse when acting in professional capacity should at all times maintain standards of personal conduct which credit up on the profession.

Nurses and co-workers The nurse maintains a cooperative relationship with coworkers in nursing and other fields. The nurse takes appropriate action to safeguard the individual when his care is endangered by a coworker or 14

Mr.Channabasappa.K.M PCON any person. Nurses and the profession The nurses play a major role in determining and implementing desirable standards of nursing practice. The nursing is active in developing a core of professional knowledge. The nurse acting through the professional organizations participates in establishing and maintaining equitable social and economic working conditions in nursing. FUNCTIONS OF ETHICAL CODES To inform the public about the minimum standards of the profession and to help them understand professional nursing conduct. To provide a sign of the professions commitment to the public it serves. To outline the major ethical considerations of the profession. To provide general guidelines for professional behavior To guide the profession in self regulations. CODE OF PROFESSIONAL CONDUCT Code of professional conduct (for nurses in India) 1. PROFESSIONAL RESPONSIBILITY AND ACCOUNTABILITY To maintain professional responsibility and accountability, the nurse a. b. c. d. e. f. g. h. Appreciates a sense of self-worth and nurtures it. Maintains standards of professional conduct, reflecting credit upon the profession. Carries out responsibilities within the frame work of professional boundaries. Is accountable for maintaining practice standards set by the I.N.C. Is accountable for his or her actions. Is compassionate. Practices healthful behavior. Is responsible for continuous improvement of current practices.

2. NURSING PRACTICE a. In the course of practice of nursing, the nurse b. Provide care in accordance with set standards of practice. c. Treats all individual and family with human dignity in providing the physical, psychological, emotional, social and spiritual aspects of care. d. Respects individuals and families in the context of traditional and cultural practices, promoting healthy practices, and discouraging harmful practices. e. Presents realistic pictures truthful in all situations for facilitating autonomous decisions making by individuals and families. f. Promote participation of individuals and significant others in the care. g. Ensures safe practice.

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3.COMMUNICATION AND INTER PERSONAL RELATIONSHIPS This plays a key role in the interaction of the nurse with his or her clients. To effect optimal interaction, the nurse a. b. c. d. Establishes and maintains effective IPRs with individuals, families and communities. Upholds the dignity of team members and maintains effective IPR with them. Appreciates and nurtures the professional role of team members. Co-operates with other health professionals to meet the needs of the individuals, families and communities.

4. VALUING HUMAN BEINGS The nurse values human life. She a) Takes appropriate action to protect individuals from harmful unethical practices. b) Considers relevant facts while taking conscientious decisions in the best interest of individuals. c) Encourage and supports individual in their right to speak for themselves on issues affecting health and welfare. d) Respect and supports choices made by individuals.

5. MANAGEMENT Proper management of resources and infra structure is essential for improving the overall efficiency of the nurse. Hence the nurses a) Ensures appropriate allocation and utilization of available resources. b) Participates in super vision and education of students and other formal providers. c) Uses judgment in relation to individual competence while accepting and delegating responsibility. d) Communicates effectively following appropriate channels of communication. e) Participates is performance appraisal. f) Participates in evaluation of nursing services. g) Participates in policy decision, following the principles of equity and accessibility of service.

6. PROFESSIONAL ADVANCEMENT To ensure that he or she is at par with contemporaries in the nursing field, the nurse must a. Ensures the protection of human rights, while pursuing the advancement of knowledge b.Participate in determining and implementing quality care. c. Take responsibility of updating ones own knowledge and competencies. d.Contribute to the core of professional knowledge and conducting and participating in research. e. The nurses responsibility for the patient has been changed to a broader term of people. This includes respect for culture, customs, religious beliefs and confidential treatment of personal information. One of our greater adjustments in nursing is accepting responsibility for our own professional behavior.

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Mr.Channabasappa.K.M PCON

LEGAL SYSTEM 1. LAW

MEANING Legal - Established by or founded upon law or official or accepted rules Law - The term law is derived from its tentoric root lag which means something which lies fixed or events - Law means a body of rules to guide human action - Law means that which is laid down or fixed DEFINITION 1) The law us a system of rights and obligations which the state enforces. By Green 2) The law constitutes body of principles recognized or enforced by public and regular tribunals has the administration of justiceby pound 3) The law is the body of principles recognized and applied by the state and the administration of justiceby salmaind 4) Law is a rule or standard of human conduct established & enforced by authority, society or custom

SOURCES OF LAW Constitutional law: - it is a judgmental law. Law that governs the state. It determines structure of state, power and duties. Common law:- it is a body of legal principles that evolved from court decisions Administrative law: - rules and regulations established by administrative agencies made by executives of government.

PURPOSES * To help the nurse to understand that they do have legal responsibilities in nursing practice. * To make them understand by which authority these legal responsibilities can be enforced.

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* To make them understand what areas of nursing practice can mostly create legal problems. * To describe and protect the rights of clients and nurses * Law is there for the protection of nursing practice * Law is there for the identification of the risk of liability * Law is there to assist in the decision-making process involved in nursing practice * Nurses have more responsibility *another important purposes are Safeguarding the public Safeguarding the nurse

Safeguarding the public 1) The public safety is guaranteed because the practice of nursing is restricted to those accredited practitioners who would seek to provide highest possible level of comprehensive care for the individual and the community taking in to account the total need 2) The individual is secure to the event of sickness or disability with no fear of anxiety of being cared for by a competent person Safeguarding the nurse 1) Licensure:All nurses who are in nursing practice have to possess a valid licensure, issued by the respective state nursing council/Indian nursing council 2) Good Samaritan laws:In response to health professionals, fear of malpractice claims, most states enacted Good Samaritan Laws that exempt doctors and nurses from liability when they render first during emergency. These laws limit liability and offer legal legal immunity for people helping in an emergency 3) Good rapport: Developing good rapport with the client is very important to prevent malpractice. The ability to develop good rapport with client is dependent on the nurse having good interpersonal communication skills e.g. listening 4) Standards of care:All professional practicing in the medical field are held to certain standards when administering care. It is always better to follow standards of care to avoid malpractice and do not attempt anything beyond the level of competence. 5) standing orders:-

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Mr.Channabasappa.K.M PCON Although a nurse may not legally diagnose illness or prescribe treatment, she or he may after assessing patients condition apply standing orders or treatment guideline that have been established by the physician or doctor as appropriate for certain problems and conditions

6) consent for operation and other procedures:A patient coming in to hospital still retains his rights as a citizen and his entry only denotes his willingness to undergo an investigation or a course of treatment. Any investigation or treatment of a serious nature, or an operation in which an anesthetic is used, requires the written consent of the patient. 7) correct identity:The nurse or the midwife has the great responsibility to make sure that all babies born in the hospital are correctly labeled at birth and to ensure that at no time they are placed in the wrong cot or handled to the wrong mother. 8) Counting of sponge instrument and needles:Nurses advocate that sponge, instrument and needle counts be performed for all surgical procedures taking place in operation theatre. When an instrument left in a patient body the nurse will probably t=liable for any patient injury caused by the presence of foreign body. 9) Contracts: A contract is a written or oral agreement between 2 people in which goods or services are exchanged. 10) Documentation:Documentation is by far the best once a lawsuit field. The medical record is a legal document admissible in court as evidence. LAW AFFECTING NURSES Nurse practice laws

Describes and designs the legal boundaries of nurse practice act within each state Administrative law

Created by administrative bodies such as state board of when they pass rules and regulations. Developed by groups who are appointed to governmental administrative agencies. E.g. Food, Drug & Cosmetic Act; Social Security Act; Nurse Practice Act Statutory law

Created by elected legislative bodies such as state legislatures

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Enacted law

Include all bills passed by legislative bodies whether local, state, and national LAW IN NURSING Common law

Created by judicial decisions made in courts when individual cases are decided Felony

Is a crime of serious nature that has a penalty of imprisonment for greater than one year or even death Misdemeanor

Is a less serious crime that has a penalty of a fine or imprisonment of less than one year Civil law

Protects the rights of individual persons within our society and encourage fair and equitable treatment among people Contract Law

It is the enforcement of agreements among private individuals. Employment Contracts is an example of contract law under civil law Criminal law

Prevent harm to society and provides punishment for crimes

Types of law
There are many ways in which a body of law, or the principles of law-making, can be divided into categories for the purposes of simplification. Comparative Law : The comparative lawyer works with international relations in trade and commerce, travel, government business, and many other areas depending upon the breadth of his/her knowledge and the needs of his/her employer. The field of comparative law is one in which there is a great deal of opportunity for advancement and challenging work. Public law : Public law is the body of law that governs the relationship between the individual and the state, as distinct from civil law (or `private' law) which governs the relationships between individuals. Public law is often taken to be divided into `criminal', `constitutional' and `administrative' branches, although these are not distinct in all jurisdictions. Family law: Family law attorneys deal specifically with laws having to do with family matters. There are multiple facets to each instance of representation required and knowledge of individuals and their family histories are necessary. Family law lawyers must interview each family member involved, or mediate for families so agreements can be made in an amiable or restructuring way. The most

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Mr.Channabasappa.K.M PCON common family law attorneys are the divorce lawyers, but other aspects of family law are represented as well. Child support claims and those stipulations, custody and who gets custody, visitation and length of visitation. Adoption proceedings, who can adopt, the rights of fathers, mothers, and the different statutes of each state, paternity and how it is determined, domestic abuse charges, who was abused, spousal abuse, child abuse, sexual abuse and the court's rulings, annulments of marriages and what are considered avoidable marriages, are all represented by the family law attorney. How these cases are decided by the courts and for what reasons are determined by the knowledge and representation of the family law attorney. Criminal Law : Criminal Law involves just what the label implies - people accused of crimes. Lawyers who specialize in criminal law may work on either side of the adversary process - defense or prosecution. There are many more types of law from which to choose; what you choose will depend upon your present interests and your interests as they develop in law school. There is no reason to make your decision before begin. Contract law: Contract law covers obligations established by agreement (express or implied) between private parties. Generally, contract law in transactions involving the sale of goods has become highly standardized nationwide as a result of the widespread adoption of the Uniform Commercial Code. However, there is still significant diversity in the interpretation of other kinds of contracts, depending upon the extent to which a given state has codified its common law of contracts or adopted portions of the Restatement (Second) of Contracts. Parties are permitted to agree to arbitrate disputes arising from their contracts. Under the Federal Arbitration Act (which has been interpreted to cover all contracts arising under federal or state law), arbitration clauses are generally enforceable unless the party resisting arbitration can show unconscionability or fraud or something else which undermines the entire contract.

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2. TORTS
The word Tort is derived from French word of the same spelling which means "mischief, injury, wrong, or calamity", from Latin tortus meaning twisted. Torts a civil wrong made against a person or property. Tort Law is the enforcement of duties & rights among independent of contractual agreements. It is a civil wrong committed on a person or property stemming from either a direct invasion of some legal right of the person, infraction of some public duty, or the violation of some private obligation by which damages accrue to the person. To constitute a tort, it is essential that the following conditions must be satisfied Act or omission Wrongful act or omission must be recognized by law Legal damage Legal remedy Categories of torts Torts may be categorised in a number of ways: one such way is to divide them into Negligence Torts, and Intentional Torts. Negligence Torts Negligence is a tort which depends on the existence of a breaking of the duty of care owed by one person to another. The tort of negligence provides a cause of action leading to damages, or to relief, in each case designed to protect legal rights, including those of personal safety, property, and, in some cases, intangible economic interests. Negligence actions include claims coming primarily from car accidents and personal injury accidents of many kinds, including clinical negligence, workers negligence and so forth. Product liability(warranty stuff) cases may also be considered negligence actions, but there is frequently a significant overlay of additional lawful content. The elements of negligence are:

Duty of care Breach of duty in English law|Breach of that duty Breach being a proximate cause or not too remote a cause in law Causation law Breach causing harm in fact

Intentional Torts Among intentional torts may be certain torts coming out of the occupation or use of land. One such is the tort of nuisance, which involves strict liability for a neighbor who interferes with another's enjoyment of his real property. Trespass allows owners to sue for entrances by a person (or his structure, for example an overhanging building) on their land. There is a tort of false imprisonment, and a tort of defamation, where someone

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Mr.Channabasappa.K.M PCON makes an unsupportable reason for arrest or their speech is not represented to be factual which damages the reputation of another. Statutory torts A statutory tort is like any other, in that it imposes duties on private or public parties, however they are created by the legislature, not the courts. Liability for bad or not working products is strict in most jurisdictions. The theory of risk spreading provides support for this approach. Since manufacturers are the 'cheapest cost avoiders', because they have a greater chance to seek out problems, it makes sense to give them the incentive to guard against product defects.

Nuisance Legally, the term nuisance is traditionally used in three ways: (1) to describe an activity or condition that is harmful or annoying to others (example- indecent conduct, a rubbish heap or a smoking chimney); (2) to describe the harm caused by the before-mentioned activity or condition (example- loud noises or objectionable odors); and (3) to describe a legal liability(responsibility)that arises from the combination of the two. The law of nuisance was created to stop such bothersome activities or conduct when they unreasonably interfered either with the rights of other private landowners (exampleprivate nuisance) or with the rights of the general public (example-public nuisance).

Intentional torts Intentional torts are any intentional acts that are reasonably foreseeable to cause harm to an individual, and that do so. Intentional torts have several subcategories, including torts against the person, including assault, battery, false imprisonment, intentional infliction of emotional distress, and fraud. Property torts involve any intentional interference with the property rights of the claimant(plaintiff). Those commonly recognized include trespass to land, trespass to chattels(personal property), and conversion.

Economic torts Economic torts protect people from interference with their trade or business. The area includes the doctrine of restraint of trade and has largely been submerged in the twentieth century by statutory interventions on collective labour law and modern antitrust or competition law. The "absence of any unifying principle drawing together the different heads of economic tort liability has often been remarked upon."

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1. Liability (financial accounting) Definition An obligation that legally binds an individual or company to settle a debt. When one is liable for a debt, they are responsible for paying the debt or settling a wrongful act they may have committed.[www.investorwords.com]

Types of liability Product liability Product liability is the area of law in which manufacturers, distributors, suppliers, retailers, and others who make products available to the public are held responsible for the injuries those products cause. Although the word "product" has broad connotations, product liability as an area of law is traditionally limited to products in the form of tangible personal property. Products Liability distinguishes between three major types of product liability claims:

manufacturing defect, design defect, a failure to warn (also known as marketing defects).

Strict liability In law, strict liability is a standard for liability which may exist in either a criminal or civil context. A rule specifying strict liability makes a person legally responsible for the damage and loss caused by his or her acts and omissions regardless of culpability (including fault in criminal law terms, typically the presence of mens rea). Strict liability is prominent in tort law (especially product liability), corporations law, and criminal law.Rather than focus on the behavior of the manufacturer (as in negligence), strict liability claims focus on the product itself. Under strict liability, the manufacturer is liable if the product is defective, even if the manufacturer was not negligent in making that product defective.

Vicarious liability The word 'vicarious' derives from the Latin word for 'change' or 'alternation' or 'stead' and in tort law refers to the idea of one person being liable for the harm caused by another, because of some legally relevant relationship. Public liability Public liability is part of the law of tort which focuses on civil wrongs. An applicant (the injured party) usually sues the respondent (the owner or occupier) under common law based on negligence and/or damages. Claims are usually successful when it can be shown that the owner/occupier was responsible for an injury, therefore they breached their duty of care.

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Mr.Channabasappa.K.M PCON The duty of care is very complex, but in basic terms it is the standard by which one would expect to be treated whilst one is in the care of another. Once a breach of duty of care has been established, an action brought in a common law court would most likely be successful. Based on the injuries and the losses of the applicant the court would award a financial compensation package.

Classification of accounting liabilities Current liabilities These liabilities are reasonably expected to be liquidated within a year. They usually include payables such as wages, accounts, taxes, and accounts payables, unearned revenue when adjusting entries, portions of long-term bonds to be paid this year, short-term obligations (e.g. from purchase of equipment). Current liabilities are the financial obligations payable within a short period of time, normally within one year. It is a balance sheet item, which is equal to the sum of dues within one year and all the money indebted to the establishment. Current liabilities are the short-term financial obligations.

Some of the distinguishable examples of current liabilities include accrued expenses as wages, taxes and due interest payments. Long-term liabilities Long-term liabilities these liabilities are reasonably expected not to be liquidated within a year. They usually include issued long-term bonds, notes payables, long-term leases, pension obligations, and long-term product warranties. Long-term liabilities are liabilities with a future benefit over one year, such as notes payable that mature longer than one year. In accounting, the long-term liabilities are shown on the right wing of the balance-sheet representing the sources of funds, which are generally bounded in form of capital assets.

ETHICAL COMMITTEE
Hospital Ethics Committee Introduction Most Indian hospitals have instituted such a committee principally for the purpose of checking whether proposals submitted for research meet established guidelines. Once this has been established, the researcher is permitted to proceed with his work and the committee turns to subsequent proposals. This approach make a very limited usage of the personnel recruited on such a committee. Much more can be done to improve not only the quality of research undertaken by the institution but also the care of patients in the institution.

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Mission statement of the committee The committee must start with an open statement on its aims and objectives. These should be circulated throughout the institution and feedback sought on how this can be improved. It is also necessary to review this mission statement periodically and revise it when necessary. The following could form the heads under which details can be entered:

Care of the patient in this institution. Research.

Education of the staff on biomedical ethics. How should the committee function? At the helm, There must be at least two senior persons complementing and supplementing each other. They should, preferably, belong to different disciplines. Who should be a member? The obvious answer is anyone with a deep commitment to medical ethics. It is important not to skew membership by having several persons from the same discipline. It is also essential to ensure representatives of:

administration clinicians - medical, surgical, other disciplines basic sciences social workers nurses rehabilitation personnel priests/philosophers lawyers statisticians

Subcommittees? If the ethics committee is charged with three principal goals: patient care, research and education of faculty and other personnel, it is logical to entrust each of these to a subcommittee. Monthly meetings of a large, single committee once a month over an hour and a half or two hours are unlikely to do justice to these goals. Frequency of meetings This will depend on the goals set for the committee. If the committee is only to restrict itself to processing applications for research, the number of such proposals will govern the dates on which meetings are to be held. Most ethics committees meet at least once a month in order to ensure that no research proposal is held up at the level of the committee.

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Mr.Channabasappa.K.M PCON Each member must attend at least 75% of all meetings. Structure of each meeting Silverman (1) suggests that no more than half an hour at the start of each meeting be devoted to business issues: reading the minutes of the previous meeting, reports from subcommittees, new issues. The remaining time must be used to discuss and explore the different moral values within the institution. This is where free discussion on ethics is encouraged and decisions sought on this basis. He suggests that discussions on specific cases, their reports having been prepared and circulated in advance, are most likely to yield results. Such cases could be selected with a view to provoking discussions on informed consent, the means by which diagnosis is disclosed to the patient and relations, expenditure incurred by patients, the rationale and justification for expensive tests or therapies, relevance of research being undertaken within the institute...

He also recommends that time be spent at each meeting on reviewing relevant papers on medical ethics published in recent issues of journals, the focus being on how these can be used to improve standards in the institution. Research All research proposals must conform to standard scientific and ethical guidelines. These must be scrutinised by a designated member of the committee to ensure that there is no glaring deficiency. (In case of such a deficiency, the proposal should promptly be returned to the researcher with a note on what is needed.) All proposals received before a stipulated date must be discussed at the next meeting. The committee must pay special attention to: - Will the study add substantially to existing knowledge? - Is the study scientifically, statistically and ethically valid? - Is it relevant? - Are the results of this study likely to prove harmful? Pilgaokar (1) points out that we have a moral responsibility to desist from any inquiry as soon as it becomes clear that it is likely to endanger mankind. - If experiments on animals form an essential component, are humane practices built into the project? - If human subjects are involved, special attention must be paid to how truly informed consent is obtained, what measures have been provided in case of complications that may harm the subjects and how those defaulting from the study will be followed up if a drug or implant with medium or long term action is being used. Pilgaokar (2) has summed up the requirements of truly informed consent, listing the various kinds of information that must be conveyed to subjects.

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Care of patients Is the institution providing the best possible medical care? This could be considered under the following heads:

The art of bedside medicine Relief of suffering Cure of disease Iatrogenic disease: incidence, trend over time Cost to patient: tests, drugs, other costs. Can these be lowered? Prompt attention to needs of the patient. Care of the seriously ill Dying patients The dead patient

Education of the staff within the institution This could cover all aspects of patient care and research. Other activities of an ethics committee Silverman (2) also recommends that the committee:

produces guidelines on a broad range of topics. Disclosure of diagnosis, diagnosis of brain death,requesting permission to harvest organs for trans-plantation,truly informed consent are some examples. sets up and ensures proper functioning of a forum for redressal of complaints from patients and fami-lies. This forum must receive complaints in writing, helping illiterate patients to prepare such documents. Complaints, proceedings of hearings on them, decisions and action taken must be kept on record. produces a document for the benefit of patients and their families informing them of services provided by the institution, rights of patients and relatives, their responsibilities, means by which they may seek redressal for any harm that may be done to them... surveys practices within the institution on a continuing basis: standards of patient care, unnecessary expenditure enforced on patients, obtaining truly informed consent. Patients and relatives could be polled on deficiencies/ malpractice witnessed by them and their suggestions for improvement. obtains feedback from faculty, other staff on the functioning of the ethics committee; perceived deficiencies and suggestions on how it might function more effectively. It may be necessary to permit anonymity of those making observations in order to safeguard them from victimisation and encourage free and frank observations.

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Mr.Channabasappa.K.M PCON

conducts seminars/ workshops/ mini- conferences on biomedical ethics, better research...

Why do some ethics committees fail? Committee set up for the wrong reasons: Such reasons include a) an attempt at avoiding prosecution under the heads: Consumers Protection Act; b) ensuring that research proposals made by members of the faculty sail smoothly through national and international agencies that offer grants and require clearance by a local ethics committee before they will take up the proposal for scrutiny; c) to form yet another power group within the institution that can hold the rest of the faculty to ransom. Goals that are too ambitious: Silverman (1) refers to the phase when ethics committees, like infants, fail to thrive.' When formed, there is much enthusiasm and activity by members of the committee. A little later, a feeling of frustration emerges as unrealistic goals set for the committee are not achieved. He refers to plans to educate the entire faculty and resident staff on medical ethics (including those in research) in a short while as an example of such a goal.

Lack of support by the institution:If all research protocols and matters of ethical concern are not placed before the committee and if the recommendations of the committee are flouted by the administration, demoralisation is inevitable. The committee must also be provided adequate infrastructure for its deliberations, inquiries, follow up studies and maintenance, analysis of records. It will be necessary for the committee to enter into correspondence with other experts and groups, record proceedings of its meetings, circulate the minutes, interact with experts on other ethics committees, funding agencies and similar groups. Funds and secretarial help are mandatory for the proper functioning of such a committee. The entire institution must want and welcome the formation of such a committee, seeing it as a means for improving standards, providing better care to patients and carrying out research of the highest standards. Poor selection of members on the committee:If these individuals are already short of time, it is unlikely that they will pay much attention to the tasks to be attended to on behalf of the committee. Cursory inspection of documents, little or no follow up action and frequent absences from meetings of the committee are expected consequences. The members must possess a strong motivation for improving the conditions under which patients are treated and research practiced. They should have already devoted some time and energy in identifying current slip- ups and malpractice and the means to be employed in correcting them.

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They must also be conversant with current trends in national and international biomedical ethics. Without continued self- education, they are likely to lapse into rigidity of approach and dogmatic decisions. Institutional Ethics Committee The need for Institutional Ethics Committee (IECs) in medical and research establishments resulted from the realization that affirms human rights as a prerogative of all members of society. Individual physicians and research workers may not be able to do what is right in all instances as evidenced by the number of cases on record. Institutional ethics committees vary widely in their composition, usually in an attempt to assure a broad based multi-disciplinary membership. In addition to those with research and clinical experience, many committees include representation from Pastoral Care, Social Work, and Law backgrounds, and often a member with a more academic orientation. Moreover, most committees find it important to include individuals from the lay community to help provide a patient's and public perspective.

The present medical and research scene in India is rather chaotic and irregular and therefore vulnerable to unethical practices. With globalization and shift of research focus from the developed countries to developing countries, the protection of vulnerable populations in countries like India is of utmost importance and urgency. The apex medical and research bodies at best have played a passive role till recently on ethical issues by not making a strong enough stand in public and not being persuasive enough to motivate all institutions to establish ethics committees. There has been no concerted move to either educate the public on ethical issues confronting medical practice and research or importantly, to incorporate bioethics as a subject in the medical, nursing, paramedical and biotechnology courses.

The Indian Council of Medical Research (ICMR) has published detailed guidelines on the composition and responsibilities of IECs and established ethical guidelines for biomedical research on human subjects (Published in 2006). A survey of existing IECs of various institutions in the country was initiated recently by the ICMR. Unfortunately this effort received a very unenthusiastic response. This sorry situation reflects an inadequate form of control and governance in the practice of medicine and research because the overseeing institutions are not given the necessary authority to take action against offenders, and society as a whole has not established a sensitive and interactive approach to the whole question of unethical practices.

What should be our perception of IEC? When an ethical dilemma occurs, it is not so much a question of "shall I do the wrong thing or the right thing", it is, "which good that I am trying to achieve is the better good?" An IEC is not a scientific review board - working as a gatekeeper and a regulator for experimental research and clinical trials. An IEC does not have that kind of a mandate nor does it wish to.

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Mr.Channabasappa.K.M PCON It is not a morals police force going around looking for research workers doing something unethical. It is not a quality review board or risk management committee who is supposed to cover the institution's legal situation. Then what should it be? The IIT-IEC should function like a preventive medicine department (preventing problems from arising) and concentrate its efforts on conflict resolution. IIT-IEC must bear in mind that it is a porous bi-layered membrane facing creative research on one side and maintaining society's human rights on the other. Composition of IEC IEC will have a chairman, the member secretary and members nominated by the Director. IEC will have minimum eight (8) members including

2 medical/ non medical scientists All members of the IEC should be non-institutional except the member secretary The chair should be an outsider The secretary should be a staff of this institution There should be at least 2 lady members in the committee There should be at least 5 members for a quorum No senior administrative officer of the institution should be a member An office and office staff should be available for the secretary of the IEC No outside member of the IEC should be connected with the institution or research project in any way

Some Specific roles the IECs can play are the following 1. Be available through the member secretary for clarifying ethical problems that may arise from the project and detail the ethical problem for the IEC to debate. 2. Make sure that "informed consent "has been properly obtained. There is a general belief among doctors and research workers that patients belonging to the lower socio-economic group are pretty illiterate about medical matters and therefore need not be told much about their diagnosis, management or prognosis or why a certain quantity of blood or other specimens are being collected.The findings of a survey are totally at variance with this observation.

3. Multi-center trials require a uniform protocol and a unified assessment system. There should be unlimited cross talk between IECs of institutions involved. 4. Periodic follow up should be made by the IEC after an institutional project has been sanctioned.

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5. Use of laboratory animals in research - additional inputs from physiologist, pharmacologists and pathologists should be sought by the IEC or a separate committee should be available. 6. Informed consent obtained from volunteers who are to participate in a field trial must be meticulously executed. The dangers if any spelt out, what legitimate safeguards as opposed to enticements can be offered ?what sort of compensation will be offered if something goes wrong, how will confidentially be maintained , can be biological samples obtained from the person be sent to other laboratories in india and abroad? And the proper disposal of biological samples.

7. Clinical trials of drugs or therapy conducted by clinicians /research workers attached to this institution and a collaborating one, should not only be assessed by the IEC ,but it should have a say in the quantum of largesse offered for the person's services and the final report should be made available to the IEC before it is submitted to the sponsoring agency. The ethics committee minutes of the collaborating institution should be available with the institutional PI.

8. Stem cell research. Experts and details mandatory. Procedure for Ethical Clearance for Projects 1. Clearance by the 'Technical Committee' is needed. In case of experiments involving animals, clearance from the Animal Experimentation Committee is required. 2. Submission of the proposal highlighting the Ethical aspects have to be submitted to the IEC office. Form 1 - must be filled up and attached to the submitted proposal. Clearance(s) as mentioned in (1) must also accompany the proposal. This must be submitted to the Member Secretary at least a month before the next meeting of the Ethics committee. 3. The PI will be informed of the date and time of the IEC meeting when the presentation has to be made to the IEC. 4. The IEC will issue the clearance certificate subject to all the criteria being met by the PI for the submitted proposal. 5. Submit 8 hard copies of your proposal to the IEC office with the prescribed forms. LEGAL ROLE OF THE NURSE 1) Provider of Service Ensure that client receives competent, safe, & holistic care Render care by standards of reasonable, prudent person Supervise/evaluate that which has been delegated Documentation of care Maintain clinical competency

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Mr.Channabasappa.K.M PCON 2) Responsibility of appointing and assigning 3) Responsibility in quality control 4) Responsibility for equipment 5) Responsibility for observation and reporting 6) Responsibility to protect public 7) Responsibility for record keeping and reporting 8) Responsibility for death and dying CONCLUSION All the ethics aims at safeguarding the rights of life. A nursing practice done with ethics in mind surely earns respect and preference and acceptability but certain dilemma are present today regarding each ethic and nurse should try her best to deal with these dilemma and act according to right need of the hour. The nursing profession has a lot of challenges in the 21st century. Critical components of the professional practice continue to expand and be enhanced through technology, synchronous (at the same time) and asynchronous (at different times).Along with this the nurses should work in a collaborative way to meet the identified goals.

Bibliography

Jean barrett, ward management and teaching, konark publications Basavanthappa BT. Nursing administration. 2ed. St Louis (USA): jaypee brothers medical publishers; 2009. p809-36. Potter P.A., A.G Perry(2005): fundamentals of nursing(6th edn) Elsevier publications; New Delhi; pg no:388-392, 404. Lan E Thompson, Kath M M (2005) Nursing ethics, Church hill living stone, London: pg no:54-56 Susan Leddy, J Pepper(1998)Conceptual bases of professional nursing (4th edn)Lippincott, Philadelphia:Pg no:11, 14-16 http://www.iitm.ac.in/iec http://www.issuesinmedicalethics.org/042ed051.html http://en.wikipedia.org/wiki/Long-term_liabilities http://www.economywatch.com/budget/india/liabilities.html http://www.investorwords.com/2792/liability.html http://en.wikipedia.org/wiki/Public_liability http://en.wikipedia.org/wiki/Strict_liability http://en.wikipedia.org/wiki/Tort http://en.wikipedia.org/wiki/Product_liability http://en.wikipedia.org/wiki/Law_of_the_United_States#Types_of_law

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2. TOPIC: LEGAL ISSUES IN NURSING: NEGLIGENCE, MALPRACTICE, INVASION OF PRIVACY AND DEFAMATION OF CHARACTER.

INTRODUCTION: As a nurse it has become an important necessity to be aware of the legal aspects associated with caring and helping people in the health industry today .Unfortunately, the more and more negligence cases there are the less and less people want to get in to the health care field fearing legal aspects and the inevitable law suites. The first nursing law created was that of nursing registration in 1903 and they have only evolved and expanded over the years to create a thick book which must be studied today by aspiring nurses. GENERAL OBJECTIVES: At the end of the class students will gain the knowledge about legal issues in nursing service and develop desired skills and attitudes while practicing nursing. TERMINOLOGIES: Plaintiff: A person who brings a case against someone else in a court of law. Sued: Take legal action against a person or institution. Intrusion: The action of coming in to a place or situation where you are unwelcome or uninvited. Parole: Temporary or permanent release of a prisoner before the end of a sentence. Homicide: Killing of person MEANING OF LAW: Ordinarily the term law means a body of rules to guide human action. DEFINITION OF LAW 1. The law is a system of rights and obligations which the state enforces - GREEN 2. The law is the body of principles recognized and applies by the state and the administration of justice .- SAMAIND CLASSIFICATION OF LAW: Law is divided in to civil and criminal components. CRIMINAL LAW: Criminal law applies to law that affects the general welfare of the public. A violation of criminal law is called crime and is prosecuted by the government. On conviction, a crime may be punished by imprisonment, parole condition and a loss of privilege (such as a license), a fine or any combination of these. The punishment is intended to deter others from committing the crime and to punish the violator. There are three classification of criminal crime: 1. Felony: A felony is a crime of serious nature that carried a penalty of imprisonment for greater than one year or death.This includes such act as homicide, grand larcency and a nurse act violation. 2.Misdemeanor: It is a crime of less serious nature and the penalty is usually a fine or imprisonment for less than a year. Includes lesser offenses such as traffic violation. 3. Juvenile: Crimes carried out by individuals under the age of 18 years, specific age varies by state and crime.

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Mr.Channabasappa.K.M PCON CIVIL LAW: Civil law applies to laws that regulate conduct between private individuals or businesses. A tort is a violation of a civil law in which another person is wronged. Private individuals or groups may bring a legal action to court for breach or breaking of civil law. The judgement of the court results in a plan to correct the wrong and may include a monetary payment to the wronged party. Nurses may find themselves involved with civil and criminal laws either separately or within the same situation.

LEGAL ISSUES IN NURSING: Some legal issues recur frequently in nursing practice. It is wise for the nurse to try to understand these particular issues as they relate to individual practice.

PERSONAL LIABILITY: As an educated professional, nurses are always legally responsible or liable for their action. Thus ,if a physician or supervisor asks you to do something that is contrary to your best professional judgement and says, Ill take responsibility that person is acting unwisely. The physician and supervisor giving the directions may be liable if harm results but that would not remove your liability. Although each person is legally responsible for his or her own actions, there are also situations in which a person or organization may be held liable for actions taken by others.

EMPLOYER LIABILITY: The most common situation in which a person or organization is held responsible for the actions of another is in the employer-employee relationship. In many instances ,an employer can be held responsible for torts committed by an employee. This is called the doctrine of respondent superior(let the master respond).The law holds the employer responsible for hiring qualified personnel, for establishing an appropriate environment for correct functioning and for providing supervision or direction as needed to avoid errors or harm. Therefore if a nurse, as an employee of a hospital, is guilty of malpractice, the hospital may be named in the suit.The employers liability may exist even if the employer appears to have taken precautions to prevent error. It is important to understand that this doctrine does not remove any responsibility from the individual nurse, but it extends responsibility to the employer in addition to the nurse.

CHARITABLE IMMUNITY: In some states, non-profit hospitals have charitable immunity.This means that the non profit hospital cannot be held legally liable for harm done to a patient by its employees. The employees of that nonprofit hospital are still legally for their own actions.The trend in legislation is toward the repeal of laws providing for charitable immunity.Those active in the consumer movement have argued that no institution should be relieved of responsibility in such a blanket fashion.If you are employed by a non profit institution, it is important that you know whether the law in your state provides charitable immunity for the institution.

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SUPERVISORY LIABILITY: When a nurse is in the role of charge nurse ,head nurse, supervisor or any other role which involves supervision or direction of other people ,the nurse is potentially liable for the actions of others .The supervising nurse is responsible for good exercising good judgement in a supervisory role .This includes making appropriate decisions about assignments and delegation of tasks .If an error occurs and the supervising nurse is shown to have exercised sound judgements in all decisions made in that capacity, the supervising nurse may not be held liable for the error of the subordinate .If poor judgement was used in assigning an inadequately prepared person to an important task the supervisory nurse might be liable for resulting harm. DUTY TO REPORT OR SEEK MEDICAL CARE FOR A PATIENT: A nurse who is caring for the patient has legal duty to ensure that the patient receives safe and competent care .This duty requires that the nurse maintain an appropriate standard of care and also that the nurse take action to obtain an appropriate standard of care from other professionals when that is necessary. The nurse has a duty to continue all efforts to obtain appropriate medical care for the patient. INFORMED CONSENT: Every person has the right to either consent to or refuse medical treatment. The law requires that a person give voluntary and informed consent to treatment.This consent may be either verbal or written.Written consent usually is preferred in health care to ensure that a record of consent exists.The form should state the specific proposed medical procedure or test. A nurse may present a form for a patient to sign and the nurse may sign the form as a witness to the signature. This does not transfer the legal responsibility for informed consent for medical care to the nurse .If the patient does not seem well informed, the nurse should notify the physician so that further information can be provided to the patient. The nurse has ethical obligations to assist the patient in exercising his or her rights and to assist the physician in providing appropriate care. CONSENT FOR NURSING MEASURES: Nurses must obtain a patient consent for nursing measures undertaken. This does not mean that exhaustive explanations need to be given in each situation because courts have held that patients can be expected to have some understanding of usual care. Consent for nursing measures may be verbal or implied. The nurse should remember that the patient is free to refuse any aspect of care offered. However, like the physician, the nurse is responsible for making sure that the patient is informed before making a decision. COMPETENCE TO GIVE CONSENT: A person ability to make judgements based on rational understanding is termed competence. Dementia, developmental disabilities, head injury , stroke and illness creating loss of consciousness are common causes of an inability to make judgement. Determining competence is complex issue. Illness ,age or condition alone do not determine competence. Legal competence is ultimately determined by the courts. When a person is legally determined to be incompetent, consent is obtain from legal guardian. Competence may change from day to day as person physical illness changes.

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WITHDRAWING CONSENT: Consent may be withdrawn after it is given. People have the right to change their minds.Therefore, if after one IV infusion a patient decides not to have a second one started that is his or her right.As a nurse, you have an obligation to notify the physician if the patient refuses to medical procedure or treatment. CONSENT AND MINORS: The consent of minor is usually given by a parent or legal guardian.You should also obtain the minor consent when he or she is able to give it.Increasingly, courts are emphasizing that minors be allowed a voice when it concerns matters that they are capable of understanding.This is especially true for adolescent,but this consideration should be given to any child who is seven years of age or older.When the minor refuses care and the legal guardian have authorized that care,you should not proceed until legal clarification is given.Your nursing supervisor should be consulted. CONSENT IN EMERGENCY: If a true emergency exists, consent for care is considered to be implied.The law holds that if a reasonable person were aware that the situation was life threatening,he or she would give consent for care. An exception to this made,if the person has explicitly rejected such as care in advance and any such information may be identified from patient wallet. \

FRAUD: Fraud is deliberate deception for the purpose of personal gain and is usually prosecuted as crime situations of fraud in nursing are not common. One example would be trying to obtain a better position by giving incorrect information to a prospective employer. By deliberately stating(falsly) that you had completed a nurse practitioner program to obtain a position for which you would otherwise be ineligible,you are defrauding the employer This may be prosecuted as a crime because you are also placing members of the community in danger of receiving sub standard care.You may also commit fraud by trying to cover up a nursing error to avoid legal action.Courts tend to be more harsh in decision regarding fraud represents a deliberate attempt to mislead others for your own gain and could result in harm to those assigned to your care. MEDICATION ERRORS: Some errors results from drugs with similar names ,look alike medication containers, poor systems for communication in which hand writing problems may contribute to lack of clarity. When medications errors do occur,fraud or intentional concealment may be charged and may contribute to the awarding of punitive damages as well as ordinary damages.

TORTS: Torts are civil wrongs committed by one person against another.The wrong may be physical harm, psychological harm or harm to reputation, livelihood or some other less tangible value.

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CLASSIFICATION OF TORTS: 1. Intentional torts 2. Quasi-intentional torts 3. Unintentional torts

INTENTIOAL TORTS: Assault: Assault is any intentional threat to bring about harmful or offensive contact. No actual contact is necessary .The law protects clients who afraid of harmful contact. It is an assault for a nurse to threaten to give a client for an X-ray procedure when the client has refused consent. The key issue is the client consent. In an assault lawsuit, if the clients gives consent, the nurse is not responsible. Battery: Battery is un-consented or unlawful touching of a person. For battery to occur ,the touching must occur without consent. Remember that consent may be implied rather than specifically stated. Therefore, if the patient extends an arm for injection, he cannot later charge battery, saying that he was not asked. But if the patient agreed because of a thread(assault), the touching would still be considered battery because the consent was not freely given. False imprisonment: The tort of false imprisonment occurs with unjustified restraining of a person without legal warrant. For example, this occurs when nurses restrain a client in a bounded area to keep the person from freedom but when it occurs in health care it is most often the basis of a civil suit rather than a criminal case. Any time a patient needs to be confined for his or her own safety or well being , it is best to help the understand and agree to that course of action. If the patient is not responsible, the guardian or legal representative may give permission. The third alternative is to objectively document the need in the patients record and obtain a physicians order as soon as possible .Be sure to follow the policies of the facility. All persons who have the right to make decisions for themselves, regardless of consequences you protect yourself by recording your efforts to teach the patient the need for restrictions and by reporting the patients behaviour to your supervisor and the physician. QUASI-INTENTIONAL TORTS

1. Invasion of privacy:
MEANING: Invasion of privacy n. the intrusion into the personal life of another, without just cause, which can give the person whose privacy has been invaded a right to bring a lawsuit for damages against the person or entity that intruded. However, public personages are not protected in most situations, since they have placed themselves already within the public eye, and their activities (even personal and sometimes intimate) are considered

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Mr.Channabasappa.K.M PCON newsworthy, i.e. of legitimate public interest. However, an otherwise non-public individual has a right to privacy. Types of invasion of privacy Invasion of Privacy - Intrusion of Solitude Intrusion of solitude, seclusion or into private affairs is a subset of invasion of privacy earmarked by some spying on or intruding upon another person where that person has the expectation of privacy. The place that the person will have an expectation of privacy is usually in a home or business setting. People who are out in a public place do not have the same expectation for privacy, according to most state laws, than do people who are inside their own homes.

For instance, journalist, investigators, law enforcement and others may not place wiretaps on a private individuals telephone without his or her consent. However, law enforcement, may at times circumvent this law by obtaining permission from the courts first. In rare cases, law enforcement may even obtain permission after-the-fact for the wiretaps.

Opening someone's mail is also considered to be intrusion of solitude, seclusion or private affairs. The information gathered by this form of intrusion need not be published in order for an invasion of privacy claim to succeed. Trespass is closely related to the intrusion tort and may be claimed simultaneously.

Invasion of Privacy - Appropriation of Name, Likeness or Identity The appropriation of a private person's name, likeness or identity by a person or company for commercial gain in prohibited under the invasion of privacy laws. This law pertains to a private figure and not a public figure or celebrity, who have fewer and different privacy rights.

This law was born from a couple of court decisions in the early 1900's where a private person's photograph was being used without consent for advertising purposes and without the person receiving any money for using their pictures in print. The courts recognized the common law right to privacy including a person's identity had been violated by the unauthorized commercial use. In later cases, a person's voice was also included.

Public figures, especially politicians do not have the same right to privacy in regards to appropriation of name, likeness or identity since there is much less expectation of privacy for public figures. Celebrities may sue for the appropriation of name, likeness or identity not on grounds of invasion of privacy, but rather on owning their own right to publicity and the monetary rewards (or damages) that come from using their likeness.

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Invasion of Privacy - Public Disclosure of Embarrassing Private Facts Public disclosure of embarrassing private facts is an invasion of privacy tort when the disclosure is so outrageous that it is of no public concern and it outrages the public sense of decency. In this invasion of privacy tort, the information may be truthful and yet still be considered an invasion if it is not newsworthy, the event took place in private and there was no consent to reveal the information. Divorce situations and relationship breakups may involve this kind of invasion of privacy tort.

LAW OF PRIVACY Privacy law is the area of law concerned with the protection and preservation of the privacy rights of individuals. Increasingly, governments and other public as well as private organizations collect vast amounts of personal information about individuals for a variety of purposes. The law of privacy regulates the type of information which may be collected and how this information may be used and stored.

Specific privacy laws These laws are designed to regulate specific types of information. Some examples include:

Health privacy laws Financial privacy laws Online privacy laws Communication privacy laws Privacy in one's home Information privacy law

UNINTENTIONAL TORTS

1. Negligence:
Definition 1. Negligence refers to the act of doing something or refraining from doing something that any other reasonable medical professional would do or refrain from doing in a similar situation. It goes without saying that every situation is different, and that is where the law becomes somewhat cloudy. However, when reviewing a nursing negligence case, assumptions and circumstantial evidence are taken into account to determine if there was negligence.

2. The basic and legal definition of negligence means breach of duty or injury. Standards of care in nursing generally mean those practices that "a reasonably prudent nurses would use." So a good nurse knows and understands ethics in the medical field and 40

Mr.Channabasappa.K.M PCON strives to provide excellent quality of care in order to avoid negligence. However, mistakes, which will happen, do not necessarily mean negligence has occurred. Breach of Duty Examples of breach of duty, which may be considered negligent under certain circumstances may include "doing something which a reasonably prudent person would not do, or the failure to do something which a reasonably prudent person would do, under circumstances similar to those shown by the evidence. It is the failure to use ordinary or reasonable care," according to Critical Care Nurse, a journal for high acuity, progressive and critical care.

Injury For an injury to be considered caused by negligence, records must show that the nurse failed to perform her duties with the patient in question. In such cases, the failure of duty must then be proven as directly related to the injury of the patient. For example, if a nurse fails to give medications as directed then the patient's condition worsens or he dies, the nurse may be found negligent.

Performance Failures Inadequate nursing skills or attention to tasks may result in a suit of negligence against a nurse who chronically fails to provide approved standards of care. Such incidents include, but are not limited to, habitual medication errors, failure to follow protocol or orders and improper use of equipment.

Examples of nursing negligence Common examples of nursing negligence include malnutrition, inadequate hydration, physical abuse, medication errors, and mental and emotional abuse. In nursing homes or other places of long-term care, there are also often injuries due to bedsores, infections and falls. Malnutrition and dehydration cases come from leaving a patient unattended for too long, ignoring his needs, or simply refusing to feed and provide water. Abuse comes in a variety of forms and, in many cases, nurses do not feel they will be reported, especially if the patient is mentally handicapped. Medication errors, bedsores, infections and falls are most frequently the result of carelessness and lack of paying attention to their patients as necessary.

Proof The legal review of a nursing negligence case requires proof that injury was done, and that it was the result of the nurse's care or lack thereof. There are five main elements in a nursing negligence case, and all elements must be proven in order for a case to be valid. If one or more of the elements is not present, the case may be

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difficult to pursue--(1) the nurse had a duty to perform, (2) the appropriate care was apparent in the situation, (3) there was a breach or violation of care, (4) there was an injury proven to result from the nurse's negligence, and (5) there is proof that damages occurred as a direct result of the situation.

Avoiding Negligence It is important for nurses to document their actions very closely and accurately at the time because sometimes negligence cases come about later when details are difficult to remember. Charting everything makes it easy to determine the details surrounding each action or inaction and to find a logical reason as to why it was done. This, in combination with a nurse who follows the proper scope of practice, will likely keep a nurse from being prosecuted for nursing negligence.

2. Malpractice:
Definition Malpractice is defined as improper or negligent practice by a lawyer, physician, or other professional who injures a client or patient. The fields in which a judgment of malpractice can be made are those that require training and skills beyond the level of most people's abilities. Medical malpractice is defined as a wrongful act by a physician, nurse, or other medical professional in the administration of treatment or at times, the omission of medical treatment, to a patient under his or her care. Although dentists, architects, accountants, and engineers are also liable to malpractice suits, most lawsuits of this type in the United States involve medical malpractice.

Medical malpractice is professional negligence by act or omission by a health care provider in which care provided deviates from accepted standards of practice in the medical community and causes injury or death to the patient. Standards and regulations for medical malpractice vary by country and jurisdiction within countries. Medical professionals are required to maintain professional liability insurance to offset the risk and costs of lawsuits based on medical malpractice

Why Nursing Malpractice is Increasing Nursing is a profession thats critical to the administration of healthcare, and its a profession thats in high demand. But there are not enough qualified nurses (for instance, registered nurses and licensed practical nurses) to keep up with this demand, and the result is chronic understaffing and a population of overworked nurses. While nursing shortages are not a direct cause of nursing malpractice, it does cause a couple of serious issues: 1. Nurses who work excessively long shifts may suffer from fatigue, making them more prone to commit an error. In fact, a 2004 report showed that nurses who worked a shift longer than 12.5 hours were three times more likely to make a mistake.

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Mr.Channabasappa.K.M PCON 2. Hospitals and other healthcare facilities may hire inadequately trained nurses or unlicensed nurse aides to fill a need. The less training a nurse has, the greater the risk of a medical error. In addition, miscommunication and carelessness are not uncommon in the healthcare setting and may directly cause a potentially life-threatening complication or mistake. Types of Nursing Malpractice Nursing malpractice takes many forms, including: - Medication errors giving a patient the wrong medication or the wrong dose, or dispensing medication to the wrong patient - Failure to follow a physicians orders - Delaying patient care and/or failure to monitor a patient - Incorrectly performing a procedure, or trying to perform a procedure without training -Documentation error -Failure to get informed patient consent Consequences of Nursing Malpractice

The consequences of nursing malpractice can range from minor to potentially fatal, and may include: Medication overdose

Adverse drug reaction Coma Brain, heart, kidney or other organ damage Infection Death

What Constitutes Nursing Malpractice? Not all unfortunate events in medicine are caused by malpractice. Despite what may be a common societal belief, not all unexpected, unintended, or even undesired medical results can be attributed to the fault of the healthcare provider. The law recognizes that much of nursing care requires clinical judgment. Consequently, a patient must prove 4 requisite elements to establish a malpractice case.

First, the patient must establish that there was a nurse-patient relationship. It is out of the nurse-patient relationship that a nurses duty to the patient arises. Rarely can it be said that a particular nurse had a duty to the patient if such a relationship cannot be shown. Most often, this element will be satisfied by reliance on the hospital record documenting

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the nurses involvement with some aspect of patient care. Once this is established, a duty is created. Second, the patient must establish the scope of the duty that was owed by the nurse; this is usually done though an expert witness testifying about the care that was required. Third, the patient must establish that there was a departure from "good and accepted practice." Good and accepted practice is most often defined as care that would have been provided by the ordinarily prudent nurse practicing in the particular circumstances. The care need not have been the best care or even optimum care. Furthermore, when there is more than 1 recognized method of care, a nurse will not be deemed negligent if an approved method was chosen, even if that method later turns out to be the wrong choice. As long as the defendant nurse provided care that was consistent with accepted practice, the nurse will not be found negligent, regardless of outcome.

Lastly, there must be a causal relationship between the act or acts that departed from accepted nursing care and the patients injury. This link must be established not by possibility, but by probability; thatis, it must be proved that if the nurse had not been negligent, then more likely than not, the patient would not have suffered harm. This element must also be proved by expert testimony.

Other common causes of malpractice cases against nurses include failure to properly monitor and assess the patients condition and failure to properly supervise a patient resulting in harm. Typically, negligent monitoring cases arise from a nurses failure to perform an assessment and notify the treating physician of changes. Thus, a nurses failure to obtain vital signs and report a patients deteriorating condition was held to constitute negligence.3 Similarly, when a nurse observed that a patients arm was swollen, black, and foul-smelling but failed to advise the treating physician of other clinical findings, including delirium and arm drainage, the nurse was held liable.4 Negligent supervision cases usually involve a patient who falls while getting out of bed, while ambulating, or while using the bathroom.

A nurse who concludes that an attending physician has misdiagnosed a condition or has not prescribed the appropriate course of treatment may not modify the course set by the physician simply because the nurse holds a different view. To permit that conduct would allow the nurse to perform tasks of diagnosis and treatment denied to the nurse by law. However, the nurse is not prohibited from calling on or consulting with nurse supervisors or with other physicians on the hospital staff concerning those tasks when they are within the ordinary care and skill required by the relevant standard of conduct.

Therefore, a nurse has an obligation to advocate on behalf of the patient when issues arise about the course of care or treatment being provided. Merely documenting in the chart that the order was discussed and confirmed with the ordering care provider is not

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Mr.Channabasappa.K.M PCON enough. The issue in these cases is not about allocating the responsibility of healthcare, but instead arises from the hospitals and nurses duty to keep the patient safe. Is the Hospital Responsible for the Actions of Its Nurses? Generally speaking, a principal is responsible for the acts of its agents. In law, this is known as respondeat superior. Therefore, a hospital has vicarious liability for the negligence of its nurses, which allows a patient to bring a lawsuit against either the nurse individually, or the hospital as the employer, or both.

In addition to liability arising out of respondeat superior, a hospital may also have separate institutional or corporate liability. Among its responsibilities, a hospital has a duty to the patient to ensure the competency of its nursing staff and the physicians who maintain privileges at its institution. Furthermore, the hospital is responsible for ensuring that proper drugs and equipment are available for use, and that they are not defective. The hospital also has a general duty to patients and visitors to maintain the hospital premises in a reasonably safe condition.

How Can Malpractice Actions Be Avoided? The simple answer is that they cannot be avoided. However, by utilizing the nursing process and employing critical thinking, bad outcomes that commonly lead to malpractice claims can be reduced. The steps of the nursing process are described as follows: 1. 2. 3. 4. 5. Assessment Problem/need identification Planning Implementation Evaluation

By ensuring that each step is taken and that reflection is given by using critical thinking, the likelihood of an avoidable adverse medical event occurring is less likely. In medication administration, the 5 Rs are often cited: right patient, right drug, right route, right dose, and right time. All too often 1 or more of these "rights" are violated, and a patient is injured. As with any order, guideline, directive, or principle within the nursing process, following these steps is only the beginning. To ensure that the clinical circumstances warrant implementation of the order, critical thinking is essential when administering any drug.

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7 tips on avoiding malpractice claims Careful practice and documentation help keep you out of court. 1. Document, document, document...correctly. We've all heard the maxim, "If it wasn't documented, it wasn't done." But simply documenting something isn't enough; we must document it precisely and thoroughly. Otherwise, gaps in our charting leave us vulnerable to malpractice charges.

No "one-size-fits-all" note suits all patients. Using your experience and knowledge, tailor your notes to each individual, predicting possible complications and adverse outcomes and documenting with that patient in mind. For surgical patients, include notes about your assessment of postoperative complications; for obstetric patients, add notes on fetal and maternal complications; for head-injury patients, document your frequent neurologic assessments, and so on. Include normal as well as abnormal findings.

In a lawsuit, the timing of your findings can be crucial. When did you observe a patient first move her fingers after hand surgery? What did the fetal heart monitor indicate during contractions throughout the entire second stage of labor? If the patient has a neurologic disorder, what's his level of consciousness from one assessment to the next? When you discover deviations from normal findings-the fingers are immobile, prolonged fetal heart decelerations are noted with delayed return to baseline, the Glasgow coma scale has decreased from 15 to 13-document what time you communicated this information and to whom. If you repeatedly report this information, your documentation must include this, along with whatever other efforts you made to bring your findings to the provider's attention.

When unusual incidents occur, make sure you notify the appropriate people, according to facility policy. For example, you should immediately advise your nurse-manager and risk management about any incidents that have liability potential. Keep an eye on forms: Complete all flow sheets or checklists, leaving no blanks; chart all given medications; and clearly mark discontinued medications or changed doses on the medication administration record.

2. Specifically identify individuals. Nursing entries such as, "MD aware," "nursing supervisor advised," and "visitor in room" don't help protect you. Which physician was aware? How can you prove you informed a provider when you can't identify her? What visitor was in the room? How can a witness be called to testify on your behalf when no one knows who he was? Always include at least the person's last name so he can be identified and contacted if needed.

3. Date, time, and sign every entry-and write legibly. Many plaintiffs' claims are based on the timing of events. The findings of what happened (or didn't happen), when, and in what order can determine the outcome of a case. When working in hospitals that have computerized charting, the technology helps confirm and preserve that information because the computer automatically stamps, dates, and inserts your

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Mr.Channabasappa.K.M PCON "signature" into each entry. But in facilities that still keep paper records, you need to time and date every entry. That's because as charts are taken apart for copying, pages can get separated and mixed up. Be sure to use a complete date, including the year, and record time on a 24-hour clock or specify a.m. or p.m. Make sure that your watch is in sync with the hospital's clock and that you record the time accurately. Sign every entry using a complete signature, including your license (RN, LPN, and so on). If one entry is incomplete or broken by pages, sign it anyway and write "contd." Continue it at another point and refer to the incomplete note by writing "contd. from 6/7/04, 10:15 a.m." and sign that note as well.

Working in a unit that uses flow sheets that open into several pages? If so, make sure each page has the correct date on it. Legible handwriting is important too. Sloppily written notes convey an impressionrightly or not-that your work is sloppy as well. You may save a few minutes by writing quickly, but do you really want to risk having your sloppily written notes misread? In particular, make sure your signature and status are legible so those who need you can find you easily.

4. Make sure you're aware of the facility's policies and practices. As a travel nurse, you may be in a different location as often as every few weeks, so you'll be very dependent on a thorough orientation to each facility. Review the policies and procedures manual on day one-or before you start working, if that's possible-so you have a solid understanding of the facilities' practices. Look to your nurse-manager and other staff nurses to fill you in on current practices and keep your recruiter informed if you aren't getting the direction you need.

5. Don't let understaffing drive you to adopt careless habits. Without a doubt, understaffing can contribute to errors: The Joint Commission on Accreditation of Healthcare Organizations indicates that it's a factor in 24% of its sentinel event reporting. But understaffing is no excuse, legally or ethically, for substandard nursing practice. If you're working in an understaffed unit, be meticulous about your practice. Don't make exceptions because you're busy or you're working in an unfamiliar or shortstaffed unit. If a patient is injured from a medication error that you made while taking a shortcut, no one will care about a nursing shortage. All that matters is that you departed from the standard of care and that your departure caused an injury.

So check ID bands when administering medications, avoid leaving medications at the bedside, observe the "five rights" (right patient, right medication, right dose, right route, and right time), document injection sites, label intravenous lines, and so on. That way, if you're involved in a lawsuit, you can say you followed the standard of practice for the profession. It means you did check the patient's ID band before giving him his medication, even if you'd been taking care of him for 4 days. You did so because it's part of your standard practice to do so, and you don't deviate from it.

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6. Don't drop the advocacy ball and get too task oriented. The hallmark of nursing is patient advocacy. Our education encourages us to be critical thinkers who study beyond the "hows" and understand the "whys." We assess and analyze, rather than just following routines. Make a conscious effort to keep your holistic hat on. If a patient was on a medication at home that hasn't been ordered with admission orders, ask if it should be continued in the hospital. Remember to check relevant lab values before giving medications. Push for psychiatric or social work consults if you think they're needed. Don't get so lost in what has to be done that you stop being a patient advocate.

7. Develop good relations with your patients. Bashing lawyers may be "fashionable," but lawyers don't sue hospitals, providers, and nurses; patients do. Long before lawyers get involved, a provider/ patient relationship exists, and the quality of that relationship plays a large role in the patient's decision to seek out an attorney. You can shape your relationship with patients in a manner that protects you or in a manner than endangers you. From your own perspective, if someone causes you harm, whom are you more likely to sue? Someone you had a good relationship with, who made you feel she cared about you, and who treated you with dignity and respect? Or someone who was dismissive, took no personal interest in you, disregarded your privacy, and treated you coldly?

Patients remember nursing care more than any other hospital experience. Establishing and maintaining good relationships with your patients will go a long way toward creating goodwill. LEGAL ISSUES IN NURSING: Some legal issues recur frequently in nursing practice. It is wise for the nurse to try to understand these particular issues as they relate to individual practice. DOS AND DONTS FOR SAFE PRACTICE: 1. Do document all unusual incidences 2. Do report all unusual incidences 3. Do follow policies and procedures as established by your employing agency. 4. Do keep current year to practice 5. Do perform procedures that you have been thought and that are within the standard scope of your practice 6. Do not work as a nurse in state in which you are not licensed 7. Do protect the patient from injury 8. Do not advice that is contrary to the doctors order or nursing care plan

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Mr.Channabasappa.K.M PCON LEGAL RESPONSIBILITIES OF NURSE: 1. Responsibility of appointing and assigning 2. Responsibility in quality control 3. Responsibility for equipment 4. Responsibility for observation and reporting 5. Responsibility to protect public 6. Responsibility for record keeping and reporting 7. Responsibility for death and dying ROLE AND FUNCTIONS OF NURSE MANAGER IN LEGAL ISSUES. 1. Serves as a role model by providing nursing care that meets or exceeds accepted standards of care. 2. Reports substandard nursing care to appropriate authorities 3. Fosters nurse-patient relationships that are respectful, caring and honest thus reducing the possibility of future lawsuits 4. Joint and actively supports professional organizations to strengthen the lobbying efforts of nurses in health care legislation 5. Practices nursing within the area of individual competence 6. Prioritizes patients right and welfare first in decision making 7. Delegates to subordinates wisely , looking at the managers scope of practice and that of those they supervise. 8. Uses foreseability of harm in delegation and staffing decision 9. Increases staff awareness of intentional torts and assist them in developing strategies to reduce their liability in these areas 10. Provides educational and training opportunities for staff on legal issues affecting nursing practice.

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3.PATIENT CARE ISSUES, MANAGEMENT ISSUES, EMPLOYMENT ISSUES AND MEDICO LEGAL ISSUES
INTRODUCTION Nursing is defined as providing care to the healthy or sick individuals for preventive, promotive, curative and rehabilitative needs. The Consumers are patients with complex needs. With increased awareness of health care, health care facilities and consumer protection Act, patients/clients are getting awareness about their rights. Nurses also have now the expanded role, with the result the legal responsibility is increased. Hence, it is important for nursing personnel working in hospital, community and educational field to develop understanding of Legal and Ethical issues of Nursing.

Issues need deliberations and common consensus. They need to be reviewed periodically. Issues which seem not feasible, and ideal, may become practice with the change of time. Some of these issues threaten nurses who do not keep up with the changing development. These issues are base for the future trends in care.

TERMINOLOGY Issue: An issue is a topic of interest which leads into a discussion and requiring a decision. Mandatory: Conveying a command. Fraud: Willful and purposeful interpretation or misinterpreting the outcome of procedure or a treatment. False Imprisonment: A person cannot be legally forced to remain in health Centers or hospital. Act: Act is a written law. When law is passed in the assembly and is approved by Government it is called as an Act. Legislation: Legislation as the process of making laws. Legislation is a method of improving public services. To control and maintain standard in nursing education and nursing practice. Legal Responsibility: Legal responsibility refers to the ways in which a nurse is expected to follow the rules and regulations prescribed for nursing practice. These responsibilities are described by State, Central Government through service conduct rules based on standards developed by State Nursing Council and National Nursing Council. Felony: Punishable by imprisonment for > 1 year. Quacks: An unqualified practiser of medicine. Malpractice: Professional misconduct; negligence performed in professional practice; any unreasonable lack of skill in professional duties or illegal or immoral conduct that results in injury or death to the client/consumer. Negligence: Negligence is described as lack of proper care and attention; carelessness.

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Mr.Channabasappa.K.M PCON Crime/ Torts: It refers a wrong commited by a person against another person or his or her property. Crime: It is a violation punishable by the state. Torts: It is gross negligence. Intentional Torts: Intentional torts are, when others interfere in individuals privacy, mobility, property or personal interests. Assault: It is a threat or an attempt to make bodily contact with another person without that persons consent. Battery: It is an assault that is carried out with willful angry and violent or negligent touching of another persons body or clothes. Defamation: Publication of a false statement about an individual made either verbally or in some other form to the third person, which damages his/her reputation? Causation: Failure to use appropriate safety measures. Liability: The state of being liable, a person or thing that is troublesome as an unwelcome responsibility, a handicap. MEANING OF LEGAL ISSUES It is a standard or rules of conduct established and inforced by the government. These are intended to protect the public. A. PATIENT CARE ISSUES Nursing covers a wide range of disciplines and health-care issues that are always changing and at the forefront of what guides this career path. Issues such as health-care reform, nursing shortages, low salaries and ethics are some of the issues being faced. With nursing being an integral part of hospitals, nursing homes, home health agencies and colleges, the discipline has to keep current of changing policies and be prepared to address whatever may arise.

a. Nursing Shortage The nursing shortage is a major issue facing the biggest licensed profession in the healthcare system. This shortage will affect health care more each day, as it appears not much is being done to stop it. Many emergency rooms have longer wait times due to less nursing staff, and hospital floors are feeling the effects as well. This is affecting patient care because the number of patients to one nurse is increasing, therefore decreasing the quality of care. This shortage is being felt in hospitals, nursing homes and home-health agencies. Nursing has been lobbying for patients by seeking legislation to help with the nursing shortage and with funding for nursing schools.

b. Health-Care Reform Nurses have always been involved with health-care reform as advocates for patients. The American Nursing Association (ANA) has been working to have the voice of nurses 51

heard. Nurses are in support of a public plan, so Americans who are underinsured or uninsured will have access to affordable, quality health insurance. The ANA has taken the stand that health care is not a privilege but a right. It is lobbying for a reduction in cost and an end to high out-of-pocket costs for services, as well as ending discrimination pertaining to pre-existing conditions. c. Low salaries d. Standard Care State Nurse Practice Act ANA-Standards of Clinical Nursing Practice National Association of School Nurses (NASN) School policy and protocols B. MANAGEMENT ISSUES Nurses working in doctors' offices and hospitals have a difficult job caring for patients and meeting the needs of both coworkers and superiors within the institution. Nurse Managers who work in the medical professional also have a complex and challenging role. It is a considerable challenge to meet the needs of the organization, the needs of patients, and the needs of the nurse employees. a. Turnover Maintaining adequate staffing levels is a major issue in nursing management. Representatives working in nurse management and leadership are often faced with the responsibility of controlling turnover rates. Nurses faced with long work hours for relatively little pay have few motivations to remain in one position and often seek employment opportunities at competing hospitals and neighboring clinics. b. Funding Lack of funding is an issue for many nurse managers who seek to provide sufficient compensation to existing nurses as well as offer suitable compensation in an attempt to recruit new nursing professionals for hire. An underfunded institution cannot attract and provide for the right professionals, and funding inadequacies can also become a detriment to the level of training provided to medical staff, in addition to the needs for medical equipment and supplies. When the medical institution's quality of staff and training standards must be lowered because of budgetary concerns, the overall level of patient care is unavoidably reduced.

c. Workload Individual nurse manager workload and overall medical workload are issues in leadership. The medical profession is one that never sleeps and has an almost constant need for qualified professionals both in hiring and scheduling. Not only do nurse professionals work long hours and many days per week, but nurse managers and leaders are also faced with an ever-increasing workload. Dealing with patient concerns, providing training and

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Mr.Channabasappa.K.M PCON support to nurses, and acting as a liaison between doctors, nurses and medical administration members can be taxing and stressful. Many nurses are unwilling to enter into the nurse management field because of the added stress and responsibility. When you add to all that the secondary stresses of budgetary cutbacks and fewer nurse leadership roles, it means that existing nurse managers are faced with enormous challenges when it comes to balancing their leadership functions.

d. Issues regarding malpractice in nursing management Issues of delegation and supervision The failure to delegate and supervise within acceptable standards of professional practice.

Issues related to staffing Inadequate accreditation standards- adequate number of staff members in a time of advancing patient activity and limited resources. Inadequate staffing, i.e. short staffing. Floating staff from unit to unit.

e. Ethics Nurses are held to a high standard of ethics when it comes to patients, co-workers and themselves. They provide care, promote human rights and values, and help meet the needs of the less fortunate and vulnerable. A major ethical goal is to also keep patients' information confidential, and this includes not discussing patients in public places. Another ethical issue is protecting patients from negligent co-workers who may endanger them. The individual nurse must not endanger the patient and has to be accountable to the standards of the field.

f. Effect Effects of reform, shortages, ethics and salaries are issues that keep nurses constantly thinking, growing and changing. Nursing instructors make far less money than nurses in the clinical setting. They also make less than other educators in different fields. In order for nursing to succeed, there needs to be qualified candidates educated, but with these low salaries nurses are not flocking to this career path. Without these types of nurses being adequately filled then qualified candidates will not have the opportunity to be taught. These salaries need to be increased, and colleges and universities need to see the value in these instructors.

g. Issues in Nursing Curriculum Development Where are we now?

As nursing faculty we need to answer the question and analyze the present situation whether or not we are on the road to relevant, which means the validation of curriculum or judgemental process in which an attempts is to be made to ascribe a degree of worth or

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value to a curriculum in the context of professional education and preparation of participants for their professional role. Walker describes five types of validation Academic validation Professional validation Economic validation Institutional validation Performance validation Then identify the strengths of present system/situation before starting the program. Where we want to go?

This deals with the thinking and aspiration for future. Faculty must think whether the educational program what is designed will help to meet the expectations of individuals, families and communities in accordance far with the developed countries or not. What we want to achieve?

Nurse educators must be able to analyze and think critically that we are preparing the students with the adequate skills to perform their expected roles in all the three domains of professional tasks such as practical, communication and intellectual skills according to the institutional goals and educational objectives. The three types of skills to be achieved: Domain of attitudes (communication skills) For example, feelings, values and interpersonal relationships Domain of practical skills (imitation control and automatism) Domain of intellectual skills(knowledge and recall of facts) For example, Interpretation of data and problem solving. How can we achieve?

The faculty must think the ways by which the curriculum can be developed to which is relevant to meet the needs of the country. h. Collaboration issues The nursing profession is faced with increasingly complex health care issues driven by technological and medical advancements an ageing population, increased numbers of people living with chronic disease, and spiraling costs. Collaborative partnerships between educational institutions and service agencies have been viewed as one way to provide research which ensures an evolving health care system with comprehensive and coordinated services that are evidence- based, cost effective and improve health care outcomes. These partnerships also ensure the continuing development of the professional expertise necessary to meet these challenges.

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Mr.Channabasappa.K.M PCON C. EMPLOYMENT ISSUES a. Issues related to Nursing Shortage The nursing shortage is another international event. Why is there a nursing shortage? There are many opinions regarding that question. I have been a nurse long enough to recognize that nursing shortages wax and wane. This shortage is more noticeable, however and it is lasting longer. The nurse shortage itself is a contributing factor because the shortage creates staffing problems, mandatory overtime, and constant calls for additional shift work.

National nursing organizations are making strong efforts at stopping the shortage by mandating better nurse- to-patient ratios, eliminating mandatory overtime, and increasing salaries and benefits for nurses. b. Issues in Nurse Migration Nurse migration has attracted a great deal of political as well as media attention in recent years. The rights to healthcare as well as workers rights are paramount to understanding the interests of health sector stakeholders, including the consumer or patient, the government or employer, and the worker or health professional. In this section a discussion on the right to work and the right to practice is, by necessity, followed by a warning that cases of exploitation and discrimination often occur when dealing with a vulnerable migrant population. Additionally, international migration policy issues addressing the somewhat conflicting sets of stakeholders' rights are presented, and ethical questions related to nurse migration are noted.

c. The Right to Work and the Right to Practice Professionally active nurses are important players in an increasingly competitive and global labor market. Unable to meet domestic need and demand, many industrialized countries are looking abroad for a solution to their workforce shortages; the magnitude of current international recruitment is unprecedented (ICN, 2005). For nurses to practice their profession internationally, they need to meet both professional standards and migration criteria. The right to practice, e.g., to hold a license or registration, a professional criteria, and the right to work, e.g. to hold a work permit, a migration criteria, are sometimes linked. Yet they often require a different set of procedures with a distinct set of competent authorities. In the interest of public safety, nurses' qualifications must be screened in a systematic way to ensure they meet the minimum professional standards of the country where they are to deliver care. This may be in the form of a paper screen, for example automatic recognition of qualifications received from a given country or school; tests, such as the NCLEX licensing exam; supervised clinical practice, as seen in an adaptation period; and/or successful completion of an orientation course/program.

Language is a crucial vehicle for the vital communication needed both between the patient and care provider, and also between members of the health team. It is not surprising that in many countries, a nurse's right to practice is limited if the foreign55

educated nurse's language skills do not support safe care practices. Passing specific language tests are required in certain countries. In others, the employer is held responsible for ascertaining the language competence of the employees/health professionals. Clearly, history has demonstrated a tendency for migrant flows to be the strongest between source and destination countries that share a common language (Kingma, 2006). For example, nurses wishing to migrate from Morocco will tend to go to France while nurses from Ghana will be attracted by the United Kingdom. As the pools of nurses willing to migrate change, and as language competency becomes a professional advancement requirement, language barriers may prove to be less of a constraint, and we may see Chinese nurses working in Ireland and Korean nurses going to the US.

Foreign nurses also need to meet national security and immigration criteria in-order-to enter the country and to stay on a permanent or temporary basis, with or without access to employment. There is no doubt that nurse mobility will be affected by national security concerns and decisions on how fluid the borders will be maintained. For example a tightening of border restrictions after terrorism attacks or the opening of borders with new economic agreements, such as the expansion of the European Union, will continue to influence nurse migration patterns.

d. Exploitation and Discrimination One of the most serious problems migrant nurses encounter in their new community and workplace is that of racism and its resulting discrimination (Chandra & amp; Willis, 2005). Incidents are, however, often hidden by a blanket of silence and therefore difficult to quantify (Kingma, 1999). Migrant nurses are frequent victims of poorly enforced equal opportunity policies and pervasive double standards. Some migrant nurses are experiencing dramatic situations on the job where colleagues purposefully misunderstand, undermine their professional skills, refuse to help, and sometimes bully them, thus increasing their sense of isolation (Allan & amp; Larsen, 2003; Hawthorne, 2001; Kingma, 2006). If we recognize that international migration will continue and probably increase in coming years, the protection of workers is a priority issue and should be safeguarded in all policies and practices that affect migrant health professionals.

e. Essential Terms and Conditions in an Employment contract An employment relationship has traditionally been governed by the terms and conditions of the employment contract. Previously, the employer retained sole control in respect of the terms and conditions of employment to be incorporated into the employment contract. However, over the years there has been an increase in the implied terms and conditions which are also read into the contract. Additionally, then there are the statutory terms and conditions which also apply. A badly drafted employment contract which does not correctly express the intentions of the employer on such matters as working hours, prolonged illness, bonus payments, usage of office computer facilities, transfers, retirement age, confidentiality, conflict of interest, disciplinary action and imposition of punishment, etc or the omission to mention some of these items in an employment

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Mr.Channabasappa.K.M PCON contract can give rise to serious consequences for employers. This talk will focus on what are considered as essential terms and conditions which employers must incorporate into an employment contract and the consequences of failure to do so. f. Unsatisfactory work performance and termination of employment The Courts have time and again reiterated that employees enjoy security of tenure of employment. The maxim "easy to hire difficult to fire" is a truism even in the case of probationers. No employer having hired a person at considerable cost and having exposed the person to training, formal or otherwise, will want to terminate the person. However, when an employee has an attitude problem or whose work performance is not up to the expectations he cannot be terminated by the employer simply by invoking the termination clause in the employment contract. The employer has to follow certain rules and procedures and only at the end of it can he terminate the services of a non-performing employee. Even then, there are no iron clad assurances that the termination will not be challenged by the employee at the Industrial Court. How does an employer ensure that he minimizes the risk of being challenged in Court over a termination of employment due to unsatisfactory work performance? This talk will attempt to take you out of the labyrinth.

g. Misconduct and imposition of punishment It has long been held that the employer has the inherent right to discipline his workers. Should misconduct be committed, the employer after a proper inquiry has been instituted can impose a suitable punishment, including dismissal if the offence committed was of a serious nature. The decision on the type of punishment to be imposed is under all circumstances a subjective one. The Courts will interfere if, among others, the action taken by the management was perverse, baseless or unnecessarily harsh or was not just or fair. There have been occasions where employers have imposed the punishment of dismissal for misconduct which they have assessed as serious but these cases have been reviewed by the Industrial Court and the decision of the employer substituted. Given that imposition of punishment is a subjective matter, what factors or criteria should an employer apply in determining appropriate punishment for misconduct committed in employment. This talk, among others, will examine some of the issues to be taken into account.

i. Sexual harassment at the workplace Sometime ago this subject matter received a great deal of attention especially with the launching of the Code of Practice on the Prevention and Eradication of Sexual Harassment at the Workplace by the Ministry of Human Resources. However, the response to the adoption of the Code by employers was not encouraging. Some NGO's have called for the introduction of statutory measures to deal with the problem. Some recent judicial pronouncements appear to make it difficult to prove sexual harassment had indeed taken place. Regardless of all these what is the proper attitude that ought to be taken by

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employers in this matter. Do employers have a legal responsibility to safeguard their employees from sexual harassment at the workplace? To what extent can employers dictate without being accused of encroachment into a person's private life and social interaction. How is an employer to deal with sexual harassment cases and what standard of proof is called for when usually harassments are .private and confidential incidents'. j. Renewal of nursing registration So that registration office is updated with nurses in practice. Of course re- registration may qualify its periodicity and qualifications of nurses e.g. clinical experience, attendance at continuing education etc. k. Diploma vs degree in nursing for registration to practice nursing This issue need indepth study of merits and demerits as well as its feasibility before it could come on the surface. l. Specialization in clinical area It could be either through clinical experience or education. Specialization in cure and specialized care required for patients demand that nurses be highly skilled in the unit. Generalization of care seems remote and unacceptable for patients under specialized treatment. m. Nursing care standards Standards must be laid down and followed so that clients understand the quality of care expected from the nurses. D. MEDICO LEGAL ISSUES Nurses face legal issues daily. Those issues may be in connection to negligence, administering medication and advocating for the patient. The Nurse Practice Act lists all of the duties and role of a nurse, except the legal and ethical issues. If these duties and regulations are not followed, the nurse is at risk of losing his license and facing a malpractice suit. a. Legal Issues Specific to Nursing Duty to seek Medical Care for the patient It is the legal duty of the nurse to ensure that every patient receives safe and competent care. The nurse cannot guarantee the patient will receive medical care that the nurse be a strong advocate for the patient and use every resource to ensure medical care is received. If you determine that a patient in any setting needs medical care, and you do not do everything within your power to obtain that care for the patient, you have breached your duty as a nurse. Confidentiality It is a privilege to care for other people. At times, your patients will relate to you in a personal way. One of the outcomes of your relationship is that you may be told information of a personal nature.in addition to what a patient may share with you, you 58

Mr.Channabasappa.K.M PCON have access to the persons hospital records. The law requires you to treat all such information with strict confidentiality. This is also an ethical issue. Unless a patient has told you something that indicates danger to self or others, you are bound by legal and ethical principles to keep that information confidential. Permission to treat When people are admitted to hospitals, nursing homes, and home health services, they sign a document that gives the personnel in the organization permission to treat them. Every time the nurse provides nursing care to person, however, permission must be obtained. The courts have ruled that people are expected to have some understanding of basic care, which means the nurse should explain briefly what he or she is about to do. The concept of permission to treat should be in your mind as you give nursing care. For example, most personnel who pass food trays automatically ask, Are you ready to go for a walk now? These automatic questions actually are permission to treat questions. When you are giving medication, you may say, Here are your pills, Here is the new medication the doctor ordered for you. If the patient takes the medication, he or she has given you permission to treat.

Informed consent The concept of permission to treat is closely tied to the concept of informed consent. The law states the persons receiving health care must give permission to treat based on informed consent. The principle of informed consent states that the person receiving the treatment fully understands the possible outcomes, alternatives to treatment, and all possible consequences. The physician is responsible for obtaining informed consent for medical procedures, such as surgery, whereas the nurse is responsible for obtaining informed consent for nursing procedures. Each institution has forms for informed consent for complex or serious procedures, such as surgery, chemotherapy, or electroshock therapy. Check with your institution and review the forms available for informed consent. Surgical procedures commonly require informed consent. Although the law states that either verbal or written consent is acceptable, most institutions require written consent because it is the most legally binding. It is the physicians responsibility to give the surgical patient the information necessary to meet the requirements for informed consent. It often is the responsibility of the nurse to get the surgical consent from signed. Advance Directives Although the Patient Self Determination Act was passed by the U.S. Congress in 1990, it was not implemented until 1992. The act states that all the health care institutions are required to give clients or patients an opportunity to determine what lifesaving measures or life-prolonging actions they want implemented. This requirement applies to all hospitals, long term care facilities, and home health agencies and is to be done at the time of admission. The institution is required to give adequate information to the person and assist in completing any forms. In most situations, the nurse is responsible for educating patients if there is not enough information to make an informed decision.

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The purpose of advanced directives is to give the person an opportunity to make decisions regarding healthcare before an illness or a need for treatment that would prohibit making such critical decisions. Negligence The law requires nurses to provide safe and competent care. The measure of safe and competent care is the standards of care. A standard of care is the level of care that would be given by a comparable nurse in a similar situation. Negligence occurs when a person fails to perform according to the standards of care or as a reasonably prudent person would perform in the same situation. It is the responsibility of the nurse to monitor the patient. If a patient calls for a nurse to come and assist him in going to the restroom for example, the nurse is to assist, or if the is busy with another patient, have another nurse assist the patient. Ignoring the patient or responding after a lengthy delay could be considered negligence, and if the patient is hurt from trying to move himself, the nurse could face legal suits. Also, it could be considered negligence if a physician orders the nurse to administer a prescription, and the nurse did not do so.

Requirements to establish Negligence There are four legal requirements that must be met for negligence to be proved: A standard of care exists. A breach of duty or failure to meet the standard of care has occurred. Damages or injury has resulted from the breach of duty. (This could be commission of an inappropriate action or omission of a necessary or appropriate act). The injury or damage must result from the nurses negligence.

I have never met a nurse whose goal was to be negligent, but it doesnt happen. Examples of negligent acts are: Leaving a patients bed in high position with the side rails down and the patient gets confused during the night and falls out of bed. Committing medications errors of either omission (not giving the drug) or commission (giving the wrong drug). Breaking sterile technique when changing a dressing, with a resultant wound infection. Mistakenly ambulating a patient who is on bed rest.

Nurses are not supposed to make mistakes, yet the best educated and well intentioned nurse can. To avoid neglect, you need to pay attention to the details of your assignment and focus on managing your workload efficiently. It is important to practice such skills now while you are a student and have an instructor to help you determine the most effective way to get your work done.

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Mr.Channabasappa.K.M PCON Malpractice Malpractice is a term used for negligence. Malpractice specifically refers to negligence by a professional person with a license. You can be sued for malpractice once you have your LPN license. If you are a nursing assistant right now, you may be negligent, but it wouldnt be malpractice because you are not licensed. Fraud Few cases of fraud exist in nursing, but it does need to be mentioned. Fraud is a deliberate deception for the purpose of personal gain and usually is prosecuted as a crime. Most courts are harder on cases of fraud compared with cases of negligence or malpractice because fraud is deliberate and results in personal gain. Assault and Battery It is found that most nurses do not understand the definitions for assault and battery. It is important to your practice that you do understand them. Assault is the threat of unlawful touching of another, the willful attempt to harm someone. Battery is the unlawful touching of another without consent, justification, or exercise. In legal medicine battery occurs if a medical or surgical procedure is performed without patient consent. In both situations, it is not necessary for harm to occur. The events simply need to happen. If you understand and practice the caring and empowering concepts shared in this test, you should never have to be concerned about assault and battery. Assault can be verbally threatening a patient. Rather than threaten a patient, you need to use your creative tactics to assist the patient in whatever is his or her choice in the matter. You do not have to hurt the person. If you practice transpersonal caring, however you should not have to be concerned with these legal issues. False Imprisonment Preventing movement or making a person stay in a place without obtaining consent is false imprisonment. This can be done through physical or non physical means. Physical means include using restraints or locking a person in a room.Insome unique situations, restraints and locking patients in a room are acceptable behaviours.This is the case when a prisoner comes to the hospital for treatment or when a patient is a danger to self or others. In these situations, be sure you know the standards of care and the institutions policies regarding physical restraints. To restrain a person is a serious decision. It requires a physicians order and permission of the patient or the patients family members.

It used to be common practice to use restraints on nursing home residents who wandered or had other behaviours that were difficult to manage. This is no longer an acceptable standard of care. The best approach to avoiding a charge of false imprisonment is to work closely with patients who seem at risk for confinement. Talk to them, do an ongoing assessment, assign

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extra staff to assist the person, or implement some other creative way to manage the problem. To resolve such complex issues is truly practicing the art of nursing. Invasion of privacy Clients have claims for invasion of privacy, e.g. their private affairs, with which the public has no concern, have been publicized. Clients are entitled to confidential health care. All aspects of care should be free from unwanted publicity or exposure to public scrutiny. The precaution should be taken sometimes an individual right to privacy may conflict with publics right to information for e.g. in case of poison case. Nurse Practice Act Each state has what is called a Nurse Practice Act. The guidelines and laws outlined in the act pertain to all nurses who are licensed in that particular state. Nurse limitation is one of those laws. Each nurse has a limitation on what he is allowed and trained to do. He must follow the chain of command, especially with the care of a patient. If he does not have the authority or knowledge to give a prescription, analyze a lab report, or advise the patient on treatment, he may not legally do so. Any wrong information or practice he commits is punishable by the law and the patient or family may file a suit against him and the health agency or hospital he works for.

Patient's Advocate A nurse has a legal obligation to act as the patient's advocate in case of emergency. The nurse is to act as the liaison between the patient and the health care provider, such as a physician. The nurse will monitor the patient, ensuring that if any complications or abnormalities arise, a physician notified immediately. The nurse is legally obligated to keep the personal data and information of the patient private; not doing so is a violation of the code of ethics for nurses. Administering Medication Nurses are responsible for administering the correct doses and medications to patients. If the nurse gives a fatal dosage amount, she may face legal malpractice suits. It is also the responsibility to research the patient's records, or ask the patient and family members if there are any allergies or complications that may pose a risk if a certain medication is administered. Report It or Tort It Allegations of abuse are serious matters. It is the duty of the nurse to report to the proper authority when any allegations are made in regards to abuse (emotional, sexual, physical, and mental) towards a vulnerable population (children, elderly, or domestic). If no report is made, the nurse is liable for negligence or wrongdoing towards the victimized patient. Examples of legal torts Invasion of Privacy example: a nursing student observing a procedure without the client's consent or taking photos of the client. 62

Mr.Channabasappa.K.M PCON False imprisonment example is telling the client that he/she may not leave the hospital or the use of restraints. Battery example: performing procedure without consent such as resuscitation. Rights to Privacy The nurse is responsible for keeping all patient records and personal information private and only accessible to the immediate care providers, according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). If records get out or a patient's privacy is breached, the liability usually lies on the nurse because the nurse has immediate access to the chart. Document, Document, Document It is the nurse's responsibility to make sure everything that is done in regards to a patient's care (vital signs, specimen collections, noting what the patient is seen doing in the room, medication administration, etc.), is documented in the chart. If it is not documented with the proper time and what was done, the nurse can be held liable for negative outcomes. A note of caution: if there was an error made on the chart, cross it out with one line (so it is still legible) and note the correction and the cause of the error.

b. Legal Issues in specialty and practice area Maternal and infant Nursing Many legal issues are involved in the care of mother and her infant. Generally the causes of lawsuits for malpractice in this area may be divided into two categories who handling the mother and child. Lawsuits brought against physicians/ doctors and nurses differ, reflecting the well- recognized differences between these professions and their responsibilities. A likely against a doctor who is in charge of looking after mother and infant might be one of the following: Failure to diagnose a high risk pregnancy. Delay in performing a caesarean section. Improper vaginal delivery or failure to perform a caesarean section. Improper use of forceps. Incidence surrounding including labour and the use of oxytocin. Delay in arriving at the hospital. Non attendance at the delivery.

The common causes for lawsuits against nurses will include the following: Problems of medication Nurses are authorized to administration of medication. So many allegations against nurses with regard to medication dosage, route or time, and failure to monitor side 63

effects, for e.g. nurses are often involved in the administration of oxytocin for the augmentation of labour.

Failure in adequate client monitoring. Nurses are expected to monitor their clients at appropriate time intervals that depend upon the clients condition. Labour and delivery pose a unique monitoring challenge, in that there are two clients to monitor, the mother and baby. The delivering mother must be adequately monitored to prevent any maternal complications during prenatal period. Nurses have legal responsibilities regarding fetal monitoring during labour. And prompt monitoring will be continued during natal period, postnatal period to prevent complication related to mother and child in respective periods.

Failure to adequately assess the client. Every nurse regardless of the area of practice is expected by virtue of his or her licensure to be capable of performing assessment. The nurse is an important member of the health care team who is the client constantly, and responsible for the minute by minute evaluation of the client progress. Nurses in all specialty areas must maintain the higher level of assessment skills. Failure to report changes in the patient Whenever the nurses assessment indicates that the clients condition has changed, the nurse must notify the concerned physician. For example the nurses failure in reporting changes in the child, denied the physician the opportunity to intervene and possibly save the childs life. When a nurse reports a clients changed condition to the physician, the nurse feels that the physician has not responded in a manner that is in the clients best interest, the nurse must proceed up the chain of command until proper medical care is given to the client. As a patient advocate, nurses must understand that failing to notify a doctor of a problem often leads to a delay in appropriate medical care being implemented. This in turn can lead to an injury to the client and a lawsuit.

Abortions Abortion is one of the emotionally charged issues confronting nurses. Nurses cannot be forced to participate in procedures they find morally offensive. Nurses have right to refuse to assist with abortions. However, nurses cannot attempt to stop an abortion being performed. She can assist with abortion if it is performed under Medical Treatment of pregnancy Act. Nursing care of new born. There are certain legal requirements in providing nursing care for newborns, such as properly identifying the infant- mother pair as soon as possible with finger prints, foot prints and wrist bands. Standards of practice include providing a clear airway, clamping the umbilical cord, applying antibiotics or silver nitrate to the edges, and minimizing stress of dying and keeping infant warm. Resuscitation equipment must be in the delivery room.

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Mr.Channabasappa.K.M PCON When a still born infant is delivered, the nurse must record all events about the delivery. Although the atmosphere in a delivery room is disquieting, the nurse must complete legal requirement by careful documentation. Informed Consent Before treatment, diagnostic procedures, or experimental therapy, a patient must be informed of the reasons for the treatment as well as possible adverse effects and alternative treatments. The physician must obtain signed consent. The nurse must ensure that signed consent is in the patients chart before the procedure is performed.

Prenatal Screening Can detect inherited and congenital abnormalities long before birth. Early diagnosis may allow repair of an abnormality in utero. May force a patient to choose between having an abortion and assuming the emotional and financial burden of raising a severly disabled child. Some feel that the risk it poses to the fetus creates a conflict between the rights of the fetus and the parents right to know the fetuss health status. Helps the patient fully understand the procedure. Pretest and posttest counseling are essential parts of an ethical prenatal- screening program.

In vitro fertilization (IVF) With IVF, the ovum is fertilized outside the body and then implanted into the uterus. Between 15 and 20 embryos may result from a single fertilization effort. Only 3 to 5 of these embryos are implanted in the womens uterus. Ethical questions arise as to what to do with remaining embryos. Although the procedure has allowed infertile couples to have children, some are concerned that it is unnatural.

Surrogacy A surrogate mother carries a fetus for another couple, with the expectation that the couple will adopt the neonate after he is born. Questions have evolved over the surrogate mothers legal rights to the infant.

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 Fetal tissue research Fetal tissue has facilitated scientific research for Parkinsons disease, Alzheimers disease, diabetes, and other degenerative disorders. Transplanted fetal nerve cells help to generate new cells in the patient that somehow reduce symptoms. Immaturity of the fetal immune system reduces the chances of the recipient rejecting the tissue. Some are concerned whether the number of abortions will increase in response to the need for tissue and whether this is an ethical use of human tissue.

Preterm and high risk neonate treatment Medical advances have improved survival rates for high risk neonates. Some are concerned about the physical, psychosocial and economic costs. The nurse must present all available options in a compassionate, unbiased manner using simple terms. The nurse must help family members consider the pros and cons both initiating and withholding treatment.

Pediatric Nursing As in all areas of nursing practice, negligence involving pediatric clients is possible. Paediatric nurses are responsible for preventing children, in their care, from accidentally harming themselves. Cribs which sometimes have a restraining device over the top are designed to keep infants and toddlers from climbing out of bed and injuring themselves. All poisonous substances and sharp objects should be kept out of the reach of children. Children should be kept under constant surveillance to minimize opportunities for accidental harm.

It is advisable that the health care professional including nurses should report to the concerned authority if they come across the suspected cases may be liable for civil or criminal legal action. Every state and province with child abuse legislation requires that suspected child abuse or neglect be reported. HealthCare professionals such as nurses are mandated to report suspected cases. Healthcare professionals who dont report suspected child abuse or neglect may be liable for civil or criminal legal action. Paediatric nurses are responsible for protecting children from accidently harming themselves. All poisonous substances and sharp objects should be kept out of reach to the children. Children should be kept under constant surveillance to minimize opportunities for accidental harm.

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Mr.Channabasappa.K.M PCON Medical Surgical Nursing As in the case of paediatric clients, disoriented adults may require form of restraints to prevent accidental self injury. Standard care, laws and regulations about the use of restraints and supervision apply to nursing practice with medical surgical patient. Side rails are available on most hospital beds for adult patients. Some disoriented older patients may also require belt restraints to prevent them falling of the bed. If patients fall off bed and injure themselves, they may bring a lawsuit against the nurses and hospital.

Nurses are responsible for performing all procedures correctly and exercising professional judgement. A nurse who does not meet the accepted standards of practice or who perform duties in a careless fashion runs a risk of being found negligence. Some common acts of negligence in medical surgical nursing are as follows: Over looked sponges, instruments needles

In the operation theatre, it is a responsibility of the nurse to count the sponges, instruments, needles before the closure of the abdomen or any cavity. The nurse may be liable if she makes an error in their court. Burns

The professional nurse is required to know the cause and effect of any heat application so as to avoid burns. Some of the common heat applications are applications, of hot water bags, heating pads, double sitz bath etc. The nurse could be held liable if she/he neglects to take proper safety measure prior to application of such measures. Falls

The nurse could be held liable if a patient falls from the bed or due to improper securing of patient on examination table or improper application of restraint or provision of a proper bed for an unconscious patient or a child. Injury due to the use of defective apparatus or supplies

The defective bed pans infect patients. The nurse could be held liable if she uses equipment or supplies them which she or he knows to be faulty, e.g. the use of unsterilized gauze of surgical dressings. Injury due to administration of wrong medicine, wrong dosage and wrong concentration.

Administration of medicine without prescription by the concerned authority, mixing up of poisonous and non poisonous drug in cupboards leading to errors, and failing to identify right medication for right patient, in right dosage, at right time, considered as negligent act can be liable to be used. Assault and battery

Failure to take the informed consent of the patient prior to any procedure, treatment, investigation or operation, the nurse be held liable.

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Failure to report accidents

The nurse has a moral and legal responsibility to report to the concerned authority any accidents, losses or unusual occurrences. Failure to do this is an act of negligence. Maintenance of records and reports

Failure to maintain accurate record and reports or removing a position of record may also make the nurse liable. Nurses working in critical care units are also legally accountable for performing their duties. Critical care nurses require additional training and ongoing intensive education to provide them with information about advances in care methods to handle high- tech- machines and electric and electronic apparatus in addition to other critical care nursing measures. The possible legal problems for critical care nurses are associated with use of electronic monitoring devices. No monitor can be considered totally reliable and nurse must not completely depend on it. These may be electrical hazards. The equipment should be checked routinely by engineers to ensure that a patient will not receive any electrical shock.

Critical care units

Nurses working in critical care settings are legally accountable for performing their duties. Critical care nurses require additional training and ongoing in service education to provide them with information about advances in methods of patient care. Possible legal problems for critical care nurses are associated with the use of electronic monitoring devices. No monitor can be considered totally reliable, and the nurse must not completely depend on it. There may also be electrical hazards. The equipments should be checked routinely.

Psychiatric Nursing The practice of psychiatric nursing is influenced by the law, particularly in concern for the rights of patients and the quality of care they are receiving. A psychiatric nurse should be sufficiently acquainted with the legal aspects of psychiatry so that she/he can be aware of the patients rights and can avoid giving poor advice or innocently involving herself/himself in a legal entanglement. Informal Admission This type of admission to the psychiatric hospital occurs in the same way as a person is admitted to a general medical hospital, i.e. without formal or written application. The individual is then free to leave at any time, as he would be in a general medical hospital. Restraints Discharge Community Health Nursing In olden days nurses were working under the control and supervision of doctors. But in modern practice nurses are able to assess, diagnose, plan, implement and evaluate nursing care independently.

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Mr.Channabasappa.K.M PCON As we begin professional practice, it is essential to understand the law that defines the nurses responsibility and duties. Especially the community health nurse must be very careful while doing services in the community. Because there is team of people working in the hospital. Whereas in the community the community health nurses are alone and most of the time she is in a position to implement the services at home. So, she must be more careful and she should have enough knowledge on legal issues.

a. Intentional Torts Assault: It is a threat or an attempt to make bodily contact with another person without that persons consent. Battery: It is an assault that is carried out with willful angry and violent or negligent touching of another persons body or clothes. Examples: Forcibly removing patients cloth. Injection with force or when refused by patient. Pushing a patient in floor or the chair.

Defamation: It is an intentional tort makes derogatory remarks about another. Slander: oral defamation of character. Libel: Written defamation (petition) E.g. About patient or co workers. Invasion of Privacy All information should be confidential. Interacting with the family members. Avoid unnecessary exposure. Checking of all graduates or machines. Carryout research activities. Using tape recorder, video or photos.

False Imprisonment: A person cannot be legally forced to remain in health centers or hospital. (Unjustified intension) Fraud: Willful and purposeful interpretation or misinterpreting the outcome of procedure or a treatment. (License may be prosecuted under the NP Act. b. Unintentional Torts Negligence: An act of negligence may be enacting of omission or commission. Malpractice or Negligence

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 Liability: It involves four elements that must be established to prove that malpractice or negligence has occurred. Duty: Execution of safety measures. Breach of Duty: Failure to note and report to the higher authority about the seriousness. Causation: Failure to use appropriate safety measures. Damages: Lengthened hospital stay and need for rehabilitation (Injection abscess) Nurses Responsibilities Practice within the scope of nurse practice act. Observe agency policies and procedures. Establish standards by using evidence based practice. Always prefer patients welfare. Be aware of relevant law and understand the limits. Practice within the area of individual competence. Upgrade technical skills by attending continuing nursing education (CNE) and seeking certification. Following the standards of care and referral services. Ensure patient safety. Proper action for needs and problems and appropriate treatment. Monitor the programme and proper reporting. Verify the medication errors and reactions.

Legal Safe Guards of Community Health Nurses Informed consent: Granted freedom, written or oral form (procedures, expected outcome, complication, side effects, and alternative treatment. Contracts: Exchange of promises between two parties. The agreement may be written or oral. (E.g. patient and his family and health care team.) Collective bargaining: Policies, legal procedures, up to date knowledge. Competent practice: It is most important and best legal safeguard.

Respecting Legal Boundaries Institutional policies/ procedures should be adopted. Respecting individual rights. Developing rapport and working relationship with the community.

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Mr.Channabasappa.K.M PCON Keeping careful documentation for all activities.

c. Legal, Ethical, Professional Issues in Nursing.

Nurses are subject to a plethora of ethical, legal and professional duties which are too numerous to discuss within this thesis. Therefore the main professional, ethical and legal duties will be discussed. These three main duties are generally considered to be to respect a patient's confidentiality and autonomy and to recognise the duty of care that is owed to all patients. These three main duties are professional duties, however there are legal implications if they are breached, therefore they are also legal duties; ethical considerations arise in contemplation of these duties, such as consideration of when they can be breached and they are therefore ethical duties as well. Before considering the main duties, consideration will be given to the regulatory body of nursing, the GMC.

The Nursing and Midwifery Council The medical and nursing professions are bound by their own code of ethics which is enforced by disciplinary procedures. The professional governing body has for the most part a more immediate influence over the conduct of its members than does the law, which is invoked relatively rarely in medical matters. The NMC is a regulator of professional standards. Central to its regulatory function is the Register of Medical Practitioners. The register operates as a regulatory tool in two ways; first of all, by operating the register the GMC is the profession's gatekeeper, allowing entry only to those who have achieved the required standards for a 'registered medical practitioner' ('RMP'). Secondly, 'fitness to practice' proceedings against RMPs may result in their being suspended or erased from the register. As a means of pre-empting the necessity for disciplinary proceedings, the NMC issues guidance on aspects of a practitioner's duties and responsibilities in areas such as consent, confidentiality and medical research, to prevent poor practice at source. The translation of NMC guidance into conduct rests primarily, of course, on the individual conscience of members of the profession whom, it is hoped, adhere to the guidance on a day to day basis.

Respecting Confidentiality The Blue Book sets out the rules on patient confidentiality and it stipulates that Patients have a right to expect that information about them will be held in confidence by their doctors. Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to give doctors the information they need in order to provide good care. Rarely, cases may arise in which disclosure in the public interest may be justified, for example, a situation in which the failure to disclose appropriate information would expose the patient, or someone else, to a risk of death or serious harm. In addition to the civil requirement to maintain confidentiality there is a professional requirement for to maintain the patient's confidentiality and failure to do so is a breach of good medical practice and will attract sanctions. There are also professional guidelines on how a nurse must deal with a situation should she make a mistake.

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 Respecting Autonomy The right to determine what happens to ones own body is the right to autonomy. The words autonomy and autonomous are used in respect of a capacity, a condition and a right. Successful relationships between doctors and patients depend on trust. To establish that trust you must respect patients' autonomy - their right to decide whether or not to undergo any medical intervention even where a refusal may result in harm to themselves or in their own death. Patients must be given sufficient information, in a way that they can understand, to enable them to exercise their right to make informed decisions about their care.

Any adult, mentally competent person has the right in law to consent to any touching of the person. If he is touched without consent or other lawful justification, then the person has the right of action in the civil courts of suing for trespass to the person - battery where the person it actually touched, assault where he fears that he will be touched. The fact that consent has been given will normally prevents a successful claim for trespass. However, it may not prevent an action for negligence arising on the grounds that there was a breach of duty to care and inform the patient.

Common causes of Legal Issues Professional negligence. E.g. ignoring the seriousness. Practicing medical without license in the community. Obtaining nursing license by fraud or allowing others to use your license. Felony conviction for any offence. Participating in criminal abortion. E.g. Quacks. Not reporting substandard medicine or nursing care. Providing patient care while under the influence of alcohol or drugs. Giving narcotics without an order. Falsely holding oneself as family practitioner of nurse practitioners.

Processes that can be used in Professional and Legal regulation of nursing practice S.N Process Education programme is evaluated and recognized by National Accreditation Board. The state determines certain minimum requirement to practice as nurse. (e.g. Negligence, malpractice, wrong treatment and alcoholism) Entry level competence. Specific knowledge and experience in

1. Accreditation

2.

Licensure

3.

Certification

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Mr.Channabasappa.K.M PCON specified areas needed. 4. 5. Standards Nurse Practice Act Guidelines issued by councils, Qualifications, Standards, rules. Violation of rule care result in disciplinary action

Legal Safe Guards and nursing practice Physicians Order: Physician is responsible for directing medical treatment. Nurses are obligated to follow physicians oders unless they believe that the orders are not accurate or would be detrimental to the clients. A nurse carrying out an inaccurate order may be legally responsible for any harm suffered by the client. Verbal orders are not recommended because they have possibilities for error. If a verbal order is necessary, during an emergency, it should be written and signed by the physician as soon as possible, usually within 24 hours.

Short- staffing: The issue of inadequate staff may arise sometimes. Legal problems may arise if there is not enough nurse to provide competent care. If assigned to take care of more clients than is reasonable, nurse should attempt to reject assignments by informing the nursing supervisor that they are inappropriate. Nurses should not walk out when staff is inadequate because charges of ababdonment can be made.ack of experience in taking care of the type of clients in the new nursing unit. They should also request for an orientation about the unit.

Floating: Nurses are sometimes required to float from the area in which they normally practice to other nursing units. Nurses who float should inform the supervisor about any Informed consent: Granted freedom, written or oral form (procedures, expected outcome, complication, side effects, and alternative treatment. Contracts: Exchange of promises between two parties. The agreement may be written or oral. (E.g. patient and his family and health care team.) Collective bargaining: Policies, legal procedures, up to date knowledge. Competent practice: It is most important and best legal safeguard.

List of dos and donts as guidelines for safe practice Dos Documention of all unusual incidences. Report all unusual incidences. Know your job description. Follow policies and procedures as established by your employing agency. Keep your registration updated. 73

Perform procedures that you have been taught and that are within the standard scope of your practice. Protect patients from injuring themselves. Remain alert and focused. Establish and maintain rapport with patients and family. Seek and clarify orders when the patients medical condition changes. Practise safety with physicians verbal orders.

Donts Remove side rails from patients bed unless there is an order or hospital policy to do so. Allow patients to leave the hospital or nursing home unless there is an order or a signed release. Accept money or gifts from patients. Give advice that is contrary to physician orders or the nursing care plan. Give medical advice to friends and neighbours. Attempt to practice medicine. Witness a patients will. Take medications that belong to patients. Worked as a licensed practical/vocational nurse in a state in which you are not licensed.

Roles and Functions of Nurse Manager in Legal Issues The following are the leadership roles and managerial functions of a nurse manager in legal and legislative issues:a. Serve as a role model by providing nursing care that meets or exceeds accepted standards of care. b. Is current in the field and seeks professional certification to increase expertise in a specific field. c. Reports substandard nursing care appropriate authorities. d. Fosters nurse/ patients relationships that are respectful, caring and honest, thus reducing the possibility of future lawsuits. e. Joins and actively supports professional organizations to strengthen the lobbying efforts of nursing in health care legislation. f. Practices nursing within the area of the individual competence. g. Prioritizes patients rights and welfare first in decision- making. 74

Mr.Channabasappa.K.M PCON h. Demonstrates vision, risk taking, and energy in determining appropriate legal boundaries for nursing practices thus defining what nursing is and should be in the future. i. Is knowledgeable responding sources of law and legal doctrines that affect nursing practice? j. Delegates to subordinates wisely, looking at the managers scope of practice and that of those they supervise. k. Understands and adheres to institutional policies and procedures. l. Practices nursing with scope of state nursing within the scope of the state nurse practice act. m. Monitors subordinates to ensure that they have a valid, current and appropriate license to practice nursing. n. Uses foresee ability of harm in delegation and staffing decisions. o. Increases staff awareness of intentional torts and assists them in developing strategies to reduce their liability in these areas. p. Provides educational and training opportunities for staff on legal issues affecting nursing practice.

CONCLUSION The above mention administration practice are highly indispensible for effective operation of the hospital and the maintaining and practicing the above mention procedures give to the nurses for acquittal from the misuse of legal responsibility. It assists in maintaining a standard of nursing practice by making accountable under the law. It should be recognized that there are limits to the contribution law can make to some topics (Dickinson 2002). The more wider topics such as consent and confidentiality discussed above also very often require not only knowledge of the law but full understanding of the ethical and professional duties. Each patient will present a different legal, ethical or professional question and no two situations will or should be dealt with in the same way as each patient is an individual.

BIBLIOGRAPHY Books BT Basavanthappa.Nursing Administration. 2nd edition. New Delhi: Jaypee Brothers Medical Publishers; 2009. Dc Joshi, Mamta Joshi.Hospital Administration. 1st edition. New Delhi: Jaypee Brothers Medical Publishers; 2009.

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5. NURSING REGULATORY MECHANISMS AND CONSUMER ACT

INTRODUCTION The standard of nursing care delivery is set by certain regulations of nursing practice called nurse practice acts. Nurse practice acts are legally defined and describe regulations of nursing actions by an administrative board such as a state board of nurse examiners. These boards generally have the authority to regulate nursing practice and education within the states. OBJECTIVES General objectives At the end of the class the students will be able understand in detail regarding nursing regulatory mechanisms, patient rights and consumer protection act TERMINOLOGIES Appeal: (law) a legal proceeding in which the appellant resorts to a higher court for the purpose of obtaining a review of a lower court decision and a reversal of the lower court's judgment or the granting of a new trial Licensure: The act of giving a formal (usually written) authorization Accreditation: The act of granting credit or recognition (especially with respect to educational institution that maintains suitable standards) Jurisdiction: (law) the right and power to interpret and apply the law Adjournment: The act of postponing to another time or place

NURSING REGULATORY MECHANISMS The main functions of these regulations include To protect patient or society To define the scope of nursing practice To identify the minimum level of nursing care that must be provided to clients The regulatory bodies that define the laws and regulations in nursing practice are the nursing councils at the international national and state levels. Such as International council of nurses Indian nursing council State nursing council ACCREDITATION The concept of accreditation of educational programs in nursing is very important. Accrediting is the process whereby an organization or agency recognizes a college or university or a program of study as having met certain predetermined qualifications and standard Accreditation refers to a voluntary review process of educational programs by a professional organization. The organization is called an accrediting agency is invited to compare the educational quality of the program with established standard and criteria. Accreditations has four major purposes which include the following Maintenance of adequate admission requirements

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Mr.Channabasappa.K.M PCON Maintenance of minimum academic standards Stimulation of institutional self improvements, and Protection of institutions of higher education against educationally socially harmful pressures

Accreditation is vital to the welfare of institution of higher education. Accrediting organizations in higher education are generally classed into three types i. National accrediting agency ii. National professional accrediting agency iii. State accrediting bodies National agencies National accrediting agencies are concerned with appraising the total activities of the institutions of higher learning, and with safe guarding the quality of liberal education, the foundation of professional programs in colleges and universities. Each agency establishes criteria for the evaluation of institutions in its region it reviews those institutions periodically, and it publishes from time to time a list of those agencies which it has accredited. India has following all India Educational Councils: Central advisory board of education All India council for Elementary education All India council for secondary education University grants commission All India council for technical education National assessment and Accreditation council

National Professional Accrediting Agency These professional groups aim to foster research, to improve service to the public and the number of individuals admitted to the profession. Controlling admissions is vital to a professional group particularly in the early stages when the professional is struggling for status. In India, particularly in the field of health, national professional accrediting agencies have existed. Medical Council of India Indian Nursing Council Dental council of India Pharmacy council of India Central council of Indian system of Medicine

Indian nursing council, (INC) is the official accrediting agency for all programs of nursing, which include Diploma (GNM), Bsc Nursing (both basic and post basic), NM/Msc N /M.phil (Masters) and PhD (Doctoral programs in Nursing)

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NURSING LICENSURE The registry of nurses initiated by Nightingale provided institutions and clients with the means to ascertain the skills and knowledge of graduates. However, this was not enough. As nursing programs proliferated, variations developed among the programs. Educational programs were structured to meet the needs of the host hospital. Another method was needed to distinguish those trained in providing nursing care. This method led to nurses developing criteria for licensure. The primary purpose of licensure was, and still is, the protection of the public. Current licensure activities Efforts to provide common definitions of nursing practice, standards of education, and testing for entry into practice across state boundaries have been successful, although nurses are still required to apply for licensure in each state in which they practice. With the mobility of nurses, the movement toward telecommunications, and care of clients across wide distances, state boards of nursing recognized the need to provide practicing nurses with more than procedures of endorsement of their initial license. This need has led to further changes in nursing licensure. In 1997, the Delegate Assembly of the National council of state Boards of Nursing moved to a new level of nursing regulation. The assembly approved a resolution endorsing a mutual recognition model of nursing regulation. Through this model individual state boards will develop an interstate compact allowing nurses licensed in one state to practice in all other states and territories. Nurses will be responsible for following the laws and regulations of those states, although they will not be required to apply for individual state licensure.

COMPONENTS OF NURSING PRACTICE ACTS All nursing practice acts include two essential components. First each includes statements that refer to protecting the health and safety of the public. The second is protection of the title of RN. This protection is ensured by describing those individuals covered by the regulations and those excluded from the act. The legal title, registered nurse, is reserved for those meeting the requirements to practice nursing in the state. A section of each nursing practice act describes the requirements for licensure. An initial requirement is graduation from high school and an accredited nursing program.

ENTRY INTO PRACTICE Each nursing practice act includes the requirements and procedures necessary for initial entry into nursing practice. There are several steps necessary in obtaining a license to practice nursing. Candidates for licensure must submit evidence of graduation as defined by each state. Frequently a transcript of course work, a diploma or letter from the dean of the program attesting to the graduation of the applicant is necessary. A temporary permit may be available for nurses moving from one state to another. The process of obtaining a license in another state is to apply for licensure by endorsement. Nurses licensed in one jurisdiction apply for licensure in a second jurisdiction by submitting a letter to the second state board of nursing. Typically evidence for the new license is similar to that for initial licensure. In addition, proof of the nurses current license to practice will be required.

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RENEWAL OF LICENSURE In addition to outlining requirements for initial licensure, each nursing practice act includes information on renewal of licensure requirements. These regulations define the period; a license is valid and any additional requirements for renewal of licensure. All nurses are expected to remain competent to practice through various means of continuing education. CONSUMER PROTECTION ACT Till recently, all cases of disputes regarding negligence on the part of doctors or hospitals were raised in a court of law. It was filed either under the law of torts to claim damages or under the relevant sections (304A, 336,337 and 338) of the IPC, to get the negligent punished. However, after the introduction of the consumer protection act, a drastic change has taken place and litigants are preferring claims through the district, state or National forums. The two main reasons for this are that hardly any costs are involved in this procedure, and the case is decided in a short span of 3 to 4 months.

Consumer protection laws are designed to ensure fair competition and the free flow of truthful information in the marketplace. The laws are designed to prevent businesses that engage in fraud or specified unfair practices from gaining an advantage over competitors and may provide additional protection for the weak and those unable to take care of themselves. Consumer Protection laws are a form of government regulation which aim to protect the interests of consumers. For example, a government may require businesses to disclose detailed information about productsparticularly in areas where safety or public health is an issue, such as food. Consumer protection is linked to the idea of "consumer rights" (that consumers have various rights as consumers), and to the formation of consumer organizations which help consumers make better choices in the marketplace.

The Consumer Protection Act of India is also quite specific about what a complaint is, under the laws definitions. First and foremost, the complaint must be made in writing and should concern an unfair action by a business or individual acting in a commercial setting. Defects in goods or unsatisfactory service can be the subject of written complaints, as can excessively high charges for goods or services. Consumers are not charged a fee for filing such complaints. Decisions may involve complete removal of any defect in a product and replacement of the product. Refunds are specifically provided for in the law. A PRIMER ON CONSUMER PROTECTION ACT(CPA) Consumer protection act (CPA in short) was enacted by Parliament in December 1986 and came into force on 1 September 1987. The aim of act is to provide a simple, speedy and inexpensive redressal for consumer grievances relating to defective goods, deficient services and unfair trade practices. The consumer protection Act defines the obligation of traders and manufacturers as well as of service providers, and if the consumer feels that the goods provided or the services given are not to his satisfaction, are defective, and below the standards prescribed normally, he is entitled for what he has paid. 79

Under the CPA, courts have been established at District levels, as the District Consumer Redressal Forum, at the state level as the state Consumer Redressal Commission and at the National level as the National Consumer Redressal Commission. These have three members including the chairman who usually is a sitting judge or retired judge of District Court or State High Court or of Supreme Court of India, respectively, and other two members one of whom has to be a woman The District Forum can award compensation up to rupees five lakhs, while the state commission can award compensation up to rupees twenty lakhs. The National Commission usually deals with appeals made against the judgments of the state commissions, and can award any amount of compensation Though the medical profession was initially exempted from the Consumer Protection Act. As stated above, but on 13-11-1995, the Supreme Court of India in its judgment in civil appeal no 688 of 1993, in case of IMA vs VP Shanta and others held that medical practitioner can be sued under Consumer Protection Act 1986, for any negligence. The court held that any services rendered by Doctors, hospitals are covered in the service as defined under section 2 (1)(0) of the CPA 1986.

CONSUMER PROTECTION COUNCILS They are at two levels namely Central and State protection councils

Central consumer protection council The objectives of this council shall be to promote and protect the rights of consumer such as, The right to be protected against the marketing of goods and services which are hazardous to life and property The right to be informed about the quality, quantity, potency , purity, standard and price of goods and services, as the case may be so as to protect the consumer against unfair trade practices The right to be assured , wherever possible, access to variety of goods and services at competitive prices The right to be heard and to be assured that the consumers interest will receive due consideration at appropriate forums The right to seek redressal against unfair trade practices

State consumer protection councils The state council shall consists of following members The minister incharge of consumer affairs in the state Government, who shall be its Chairman and Such number of other official or non official members representing such interest as may be prescribed by state Government The State Council shall meet as and when necessary, but not less than two meetings shall be held every year

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Mr.Channabasappa.K.M PCON The objective of every state council shall be to promote and protect within the state , the rights of consumer DEFINITIONS CONSUMER Consumer means any person who hires any services for a consideration, and includes any beneficiary of such services other than the person who hires the services, when such services are availed of with the approval of the first mentioned person The status of a patient is that of a consumer, because the patient pays for the services or has the liability to which may be by full down payment, in installments or under any deferred payment system. If a person has received free services without paying for the same, he cannot be called a consumer. This is why government hospitals providing services without any charges are outside the preview of the act A person who avails himself of the facility of a government hospital is not a consumer because the facility offered in government hospitals is not service hired for a consideration. For deficiency of service in government hospitals, the aggrieved person will have to file a claim in civil court. If the conduct of the hospital doctor amounts to criminal negligence, the patient can cause to prosecute the doctor in criminal court.

COMPLAINT It means any allegation in writing made by a complainant that The goods bought by him or agreed to be bought by him suffer from one or more defects An unfair trade practice or restrictive practice has been adopted by any trade DEFECT Means any fault , imperfection or short comings in the quality, potency, purity or standard which is required to be maintained by or under any contract or as is claimed by the trader in any manner whatsoever in relation to goods. DEFECIENCY Deficiency is any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance in pursuance of a contract or otherwise in relation to the service SERVICE Service means service of any description but excludes free service and personal service. Treatment in a hospital (excluding government hospitals) on payment amounts to hiring of service for a consideration. Therefore, a complaint would lie if there is deficiency in service rendered by a member of the medical profession

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TIME LIMITATION A claim for compensation under CPA must be filed at a Forum within three years of the subject matter of the complaint (e.g.; death) having arisen If an amendment to the act, presently under consideration of the government is passed, this period is likely to be raised to one year At the district forum, a case has to be heard within three months of being filed PATIENTS BILL OF RIGHTS The health care rights of patients have been the subject of much public debate and legislative action in the latter half of the 20th century. The fundamental right to quality medical care and compensation for medical malpractice, the right to informed consent, and the right to health care privacy, are all protected under United States congressional law. While these and other laws ensure many rights for medical patients, the changing nature of medical knowledge and care also ensures the continued need to regulate the relationships among patients, care-givers, and care-giving institutions. But quite apart from any legal issues, the recognition that patients have rights can transform the doctor-patient relationship from an authoritative and paternalistic one into a true partnership, with the result that the quality of medical care is enhanced.

The government is concerned about the deteriorating services in medical care both in private nursing homes and public hospitals. Consumer organizations are also pressing for a charter of right of consumers of medical services. The legislative controls of nursing practice primarily protect the rights of the patients. Until the 1960s patients had few rights; in fact, patients often were denied basic human rights during a time when they were vulnerable. In 1973, however, the American Hospital association published its first patient bill of rights. The patient has the right to considerate and respectful care The patient has the right to and is encouraged to obtain from physicians and their direct care givers relevant, current, and understandable information concerning diagnosis, treatment and prognosis The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and notify patients of any policy that might affect patient choice within the institution The patient has the right to have an advance directive (such as living will, health care proxy or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patients privacy The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential by the hospital, except in cases such

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Mr.Channabasappa.K.M PCON as suspected abuse and public health hazards when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records The patients has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives such a transfer The patient has the right to ask and to be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patients treatment and care The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or human experimentation is entitled to the most effective care that the hospital can otherwise provide The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other care givers of available and realistic patient care options when hospital care is no longer appropriate The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospitals charges for services and available payment methods.

A bill of rights that has become law or state regulation has the most legal authority because it provides the patient with legal recourse. Today, patients are more assertive and involved in their health care. They have more information to review when looking at treatment options and are demanding to be participants in decision making about their health care. The patients right to information and participation in medical care decisions has led to conflicts in the areas of informed consent and access to medical records. Although the manager has a responsibility to see that all patient rights are met in the unit, the areas that are particularly sensitive involve the right to privacy and personal liberty, both guaranteed by the constitution.

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Patient Responsibilities In order to receive optimal care, patient and his family are responsible for:

Providing accurate information about present illness and past medical history and wishes for your medical care. Seeking clarification when necessary to fully understand health problems and the proposed plan of care. Following through on agreed plan of care. Considering and respecting the rights of others. Being courteous. Providing accurate information for insurance claims and working with the Health Systemtomake payment arrangements when necessary so that others can benefit from the services provided here. Following visitation policies of University Hospital.

CONCLUSION In the rapidly changing atmosphere of health care, many factors have affected how health care is practiced. The rights of the patient have also been affected. Patient rights have recently become the center of national attention in the practice of medicine. The push for legislation of a patients' bill of rights is to provide laws that would prevent health maintenance organizations (HMOs) and other managed health plans from refusing to pay for appropriate care. "Consumer protection law" or "consumer law" is considered an area of law that regulates private law relationships between individual consumers and the businesses that sell those goods and services. Consumer protection covers a wide range of topics, including but not necessarily limited to product liability, privacy rights, unfair business practices, fraud, misrepresentation, and other consumer/business interactions

BIBLIOGRAPHY 1. AG Chandorkar, Hospital administration and planning. Paras publishing: 2nd edition: New Delhi; 2009. 2. Barbara cherry, Susan R. Jacob. Contemporary nursing issues, trends &management: Mosby publishers; Philadelphia; 1999. 3. BT Basavanthappa, Nursing Administration. 2nd edition, Jaypee Publishers ; NewDelhi;2009

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6. Responsibilities and Accountability Introduction

"If you want the credit, you take the responsibility." What makes one employee look forward to taking on more responsibility and accountability while another one blames to avoid any responsibility? Is it all based solely on the employee, or does management play a role in creating an environment that fosters accountability and responsibility? Strategies for Building Accountability and Responsibility Tool 1: How to Hold People Responsible and Accountable Using the RACI Chart The RACI chart is designed to help people define who is Responsible, Accountable, Consulted, and Informed for the various tasks or decisions required either by individuals or teams. By completing the RACI, the manager or project leader clarifies what is expected and by whom. Responsible The person or position required to complete a task. Each task is required to have a responsible person or position assigned to it. Multiple people or positions can be assigned responsibility for completing a task. Accountable The person or position accountable for a task is responsible for insuring that it is completed on-time and in a manner which meets all expectations for it. The Accountable (A) person or position does not have to physically do the task. Accountability should be focused on the "Responsible" person whenever possible. Accountability must be assigned to each task. Consulted The person or position assigned consulting status for a task is required to be consulted with by the Responsible (R) person or party before performing a task. A task with a consulting position assigned to it must be consulted with before the task is performed. Because of the delay caused by consultations, their use should be minimized. The responsible party should be empowered to do the required task with very few exceptions. Informed The person or position assigned informed status for a task is required to be informed that a task has been completed. The person or position with the "I" can be informed before or after the fact. The Informed (I) person or position is not being informed for permission or approval. The RACI chart should initially be completed by the manager or sponsor of a team and then shared with employees or team members. The RACI is a living document that changes over time as people become more and more accountable for their results. In a team environment, the RACI is typically reviewed at the same time the team charter is being updated with new goals. Tool 2: Using Situational Leadership to Build Environments of Accountability In the 1980s as organizations moved away from the Taylor model of accountability (resting solely with management), it became popular for managers to "empower" employees to build accountability. Often uncertain what the term really meant or how to make it happen, management's implementation of empowerment often looked more like a "dump and run." It's only when we apply the Situational Leadership Model (Blanchard) that we begin to understand how and, more importantly, when to empower and build accountability over the long-term.

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The Situational Leadership Model suggests that employees develop over a long period of time by building on two components: the competence (skill and ability) and the commitment (desire and motivation) to do the task. According to Blanchard, employees typically fall into one of these four categories: D1: Low competence high commitment Often a new employee (or an experienced employee) who is given a new task. Employee has high expectations for what will happen; very enthusiastic about the future and own ability to deliver results. Often eager to please, readily volunteers and tries to do extra in order to be accepted. D2: Some competence low commitment Characterized as a "sophomore" employee who has taken a nose-dive in motivation because job expectations don't match reality; the work is more difficult than expected, and not as "flashy" as desired. This employee watches the clock, acts like a know-it-all and is critical of authority. D3: High competence variable commitment A long-term employee who has become cynical, bitter and frustrated over time. Although competent, the employee often displays negativity and procrastination. The D3 has experienced many disappointments in the work environment and has "collected stamps" about those disappointments over time. D4: High competence high commitment A star employee who brings experience and commitment to the job. They are able to set goals and deliver results. The D4 is very self-motivated and self-directed. Having examined the four developmental categories, it's easy to see that it doesn't make sense to lead, manage, supervise or coach these four types of employees in the same way. Each developmental level needs a different leadership approach to encourage responsibility and accountability. If we empower the D1, the employee will get completely lost, without a clue about what work to do or how to do it. If we direct the D4, we will be micromanaging a competent employee and, as a result, completely discourage any creativity or initiative. Instead, Situational Leadership suggests that there are four corresponding styles of leadership that must occur to drive accountability and responsibility. Leadership is based on the degrees of Directive behavior (telling and showing people what to do and providing frequent feedback) and the degree of Supportive behavior (praising, listening, encouraging and involving); the S1-S4 corresponds to the D1-D4: S1: TEACHING (high directive; high supportive) The manager provides clear direction about tasks, expectations, responsibilities and simultaneously builds a strong relationship with the employee. The manager's approach is quite directive, or what is called the "teaching" style. S2: COACHING (high directive; low supportive) The manager continues to strongly direct and teaches with input from the employee, but also "coaches" proper behavior and job expectations. The manager must correct problem behaviors using "redirection" strategies. It's also important for the manager to speak to the employee's potential. S3: SUPPORTING (low directive: high supportive) The manager places the focus on rebuilding and restoring the relationship by using a "supportive" model of listening and engaging with the employee. The goal is to get the "stamps" out so the energy can flow again. This employee does not need directive strategies, as they are very component. S4: EMPOWERING (low directive; low supportive) This star is ready to be empowered. Challenging goals are identified and the employee

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Mr.Channabasappa.K.M PCON is given great latitude to design and develop own approach. The manager only provides guidance when needed. Tool 3: Performance Management: Applying Natural Consequences to Improve Accountability A D4 is a terrific employee whom we want to challenge and keep moving along, while our D2 is a self-proclaimed know-it-all who is ready to leave ten minutes early and never seems to put in a full day's work. "Moving" the D4s behavior and "stopping" the D2s behavior is what Performance Management is all about. In order to build accountability, both need to experience the natural consequences of their own actions, positive and negative. How do we make those natural consequences occur in the workplace? Many managers are very reluctant to praise positive behavior for fear it will go to the employee's head and correct problem behavior for fear of conflicts. As a result, the manager focuses on setting goals, crafting mission and vision statements, and completing job descriptions as a way to get correct behavior. These items are what are called "antecedents." They come before the desired behavior. Aubrey Daniels, through his research in performance management, found that antecedents only cause behavior to occur once or twice. Furthermore, he discovered that it is only the consistent pairing of antecedents with consequences that drive behavior change and accountability. Consequences are defined as the natural outcomes that "move" or "stop" behavior. Consequences that "move" behavior: Positive reinforcement An individual gets what he/she wants. Not that the individual gets what we think they want (e.g., praise, a luncheon, a movie ticket). For positive reinforcement to work it must be personal; in other words, what motivates you will not necessarily motivate me. When the employee is given "what he/she wants," it will build commitment and from commitment comes accountability. Timing is critically important here as a long delay between behavior and reinforcement will make the reinforcement meaningless. Negative reinforcement An employee avoids what they don't want. The most common form of negative reinforcement is to introduce fear into the environment. "Better get that report that John wants on his desk by 4 or he won't be happy." The employee "moves" his/her behavior in order to avoid the anticipated wrath of John. These fear messages can be very subtle body language in a meeting, how a report is placed in an in-box, reading between the lines of emails, not returning phone messages. It's important to realize that fear will cause behavior to move (in order to avoid the projected consequences), however, the focus is on compliance, not commitment. The individual performs the minimums to avoid punishment. The definitions here are very important because positive reinforcement doesn't necessarily mean praise or gifts or applause. The person must get something that they truly desire. For many people, this could mean time with the manager to talk about personal growth, an afternoon off to attend a child's soccer game, or being assigned to a prestigious project. Likewise, negative reinforcement introduced an outcome that the person would like to avoid. Positive reinforcement will build commitment; negative reinforcement will only build compliance -- both, however, will move behavior. Positive reinforcement builds accountability; negative reinforcement builds avoidance of accountability and a desire to "play it safe."

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Consequences that will "stop" behavior Omission Here the employee "doesn't get something he/she wants" such as attention, recognition or special privileges. Omission is often used effectively when someone is doing behaviors that focus on getting attention or inappropriate recognition, such as clowning around, interrupting, being aggressive or sarcastic, and lateness. By omitting reinforcement, the behavior stops because the person was looking for attention and doesn't get it. The best example is of a two or three-year old who has a tantrum in the store. If the mom or dad keeps telling the child to be quiet and admonishing that he or she will go to the car, the child is getting lots of attention (albeit scolding) and the behavior is being positive reinforced (I get what I want). If, on the other hand, the parent walks away and omits reinforcement, the child will fuss for another minute or two and the stop to go find the parent. Ironically, adults act the same way sometimes: those who seek attention by complaining, blaming, requiring lots of reminders to get work in on time, lateness, interrupting, etc. Punishment The employee "gets what he/she doesn't want." Punishment is based on getting something we don't want. Typically, organizations use progressive discipline to administer punishment. However, we could be much more creative with punishment than we typically are. There are many things employees don't like to do (scribe notes, facilitate meetings, do paperwork, monotonous tasks, make phone calls, even serve on a team). All of these, if applied as punishment, would cause problem behavior to stop. Accountability must never be used as a device for placing blame or designating a scapegoat. Developing accountability does not mean relinquishing accountability on management's part. It must be perceived as a partnership. In the beginning of a group's development, management usually carries the lion's share of the accountability burden, absorbing the brunt of any disappointments. However, as the group matures, members expect to be held more accountable for their own results. Accountability begins at home, working on the messages you send out to others. Do you identify ways to hand off meaningful activities to employees using the RACI chart? Do you know the developmental levels of your employees and actively work them around to D4s? Do you appropriately use positive and negative reinforcement to "move" behavior and omission and punishment to "stop" behavior? Would some "redirection" conversations help to get a few people back on track? By position, management has responsibility and accountability. A wise manager knows, however, that he or she can't do it all and will fail if they try. Getting others to pitch in and accept accountability will be an enormous load off the manager's back. To succeed, the manager must use effective tools to build an environment of accountability A Basic Framework Several people in the NGO world have produced simple accountability frameworks.]For most NGOs, only a small part of this accountability is legally required but increasingly the bulk of it is more professionally, commercially, politically and morally demanded. Although the predominant metaphor of accountability is financial, the actual demands of NGO accountability today are much wider than a financial procedure that ensures that figures tally. Accountability is much more about reporting on relationships, intent, objectives, method and impact. As such, it deals in information which is quantitative and qualitative, hard and soft, empirical and speculative. It records facts and makes judgements. Also, current orthodoxy in accountability is as keen to embrace failure and so learn from it, as it would be to celebrate success and repeat it. The simple frameworks to date might be summarised as having four main dimensions to them.

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Mr.Channabasappa.K.M PCON Accountability for What? An accountability process should start by identifying the rights involved in any NGO programme, the relevant rights-holders and duty-bearers related to that right and the content of the duty in the situation. From this rights-duties analysis, an NGO can then identify its own specific duty and set out to account for it, while making clear the responsibilities of others. It can then account for what it does by being able to tell as true a story as possible about the piece of work that it did in a given situation. This story will involve an angle on all the different people involved, their experience of the work, the relationships that emerged, the quality and standards expected, the money that was spent, the things that it was spent on. From these perspectives, it should then be able to report on the overall impact that this combination of people, relationships, money, things and time had on the rights concerned. Accountability to Whom? In any piece of work, an NGO will need to account to different groups of people as stakeholders. These will be the targeted rights-holders, the various duty-bearers and those secondary and tertiary stakeholders beyond the primary stakeholders who operate as interested or critical observers. Accountability How? Different stakeholders will require accounting to in different ways. Some people will require figures alone. Others will require figures and impact. Some will be literate, others will not. Some will want to know a lot of detail. Others will want to know the main points. So accountability will require diverse media. Accountability processes must also involve key stakeholders through representative meetings, research, representative assemblies or voting systems. But virtues common to all NGO accountability mechanisms must be veracity and transparency. What an NGO is saying about itself, or what it reports others as saying about it, must be reasonably true, easily available and accessible to all. Accountability to Improve NGO accountability mechanisms must show clearly how the agency is responding to what it has learnt and what its stakeholders are telling it. The mechanisms chosen must demand and show responsiveness by informing people about, and involving people in, new action taken. The concept of responsibility Four-Fold Definition of Responsibility Causal Responsibility

Liability-Responsibility Role-Responsibility Moral-Responsibility

Causal Responsibility A purely descriptive sense of responsibility The heavy rain is responsible for the flooding The operator was responsible for turning off the control switch The But-For conception of being causally responsible: X was causally responsible for Y = 89

 But for the occurrence of X, Y would not have happened For Example: But for the operator turning the switch, the control would not have went off Liability-Responsibility Liability for ones actions means that one can rightly be made to pay for the adverse effects of ones actions on others Automobile liability insurance is intended to cover the costs of damage to other persons or property We are usually liable for such payments as long as we are causally responsible, even if our actions were unintentional Liability, does not necessarily involve moral responsibility for the action It means that no excusing conditions are applicable or accepted Responsibility without fault Strict Products Liability Part of the debate about legal liability concerns where the line should be drawn when assigning strict liability Role-Responsibility Role-Responsibility: Whenever a person occupies a distinctive place or office in a Social organization, to which specific duties are attachedhe or she is properly said to be responsible for the performance of these duties, or for doing what is necessary to fulfill them. Such duties are a persons (role) responsibilities.

Moral-Responsibility Moral Responsibility: Accountability for the actions one performs and the consequences they bring about, for which a moral agent could be justly punished or rewarded. It is commonly held to require the agent's freedom to have done otherwise (autonomy). Moral responsibility is a normative notionit involves an evaluation Connected to other concepts such as duty, obligation, knowledge, freedom, choice, accountability, agency, praise, blame, intention, pride, guilt, shame, conscience, and character Accountability Responsibility and blameworthiness are only a part of what is covered when we apply the robust and intuitive notion of accountability When we say someone is accountable for a harm, we may also mean that he or she is liable to punishment (e.g., must pay a fine, be censured by a professional 90

Mr.Channabasappa.K.M PCON organization, go to jail), or is liable to compensate a victim (usually by paying damages). In most actual cases these different strands of responsibility, censure, and compensation converge because those who are to blame for harms are usually those who must pay in some way or other for them. 3 Motivations for Accountability Accountability as a virtue that is desirable in its own right Accountability as a guideline for answerability which motivates precautionary behavior that, in turn, caters to social welfare Accountability as a tracing too that allows us, a posteriori, to identify the people involved in accidents and damage-inducing errors, punish the responsible if necessary and compensate the victims if possible A Typology of Moral Accountability Malice: to set out on a course of action with the deliberate aim of imposing harm or risks to people Recklessness: to act knowing that it will cause harm or risk, but not taking this properly into account Negligence: the failure to exercise in the given circumstances that degree of care for the safety of others which a reasonable person would exercise under the same or similar circumstances Incompetence: not qualified or suited for a purpose; showing lack of skill or aptitude; "a bungling workman"; "did a clumsy job"; "his fumbling attempt to put up a shelf" Competence: qualified or suited for a purpose; showing appropriate skill or aptitude Due Diligence: the exercise in the given circumstances that degree of care for the safety of others which a reasonable person would exercise under the same or similar circumstances Dutiful: to know what the right thing to do is and to do it regardless of how it effects you Supererogatory behavior: going above and beyond the call of duty. Barriers to Responsibility and Accountability 1. The Social Psychology of Identification of Ones Role in Social Interaction (The Zimbardo Experiment) 2. Obedience to Authority in Social Contexts (The Milgram Experiment) 3. The Problem of Many Hands

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4. Diffusion of Responsibility 5. Risky Shift Phenomena Barriers to Individual Accountability 1. Self-Interest 2. Fear 3. Self-Deception 4. Ignorance 5. Egocentrism 6. Narrowness of Vision 7. Uncritical Acceptance of Authority 8. Groupthink

Responsibility and Accountability for special individual & group. 1. Introduction The Occupational Safety and Health Policy, approved by the Vice-Chancellor, commits the University to ensuring a safe and healthy workplace for staff, students, contractors and visitors. This policy provides further information on the responsibilities and accountabilities for such. To effectively implement this policy, staff at all levels are required to be made aware of their responsibilities and also held accountable for their actions or inactions. This requires the ongoing incorporation of occupational safety and health (OSH) principles into work practices, the ongoing commitment of resources to OSH and communications between all levels of staff and others. All staff and students are responsible for their own safety and health and for that of others whose activities they may influence or control. The degree of responsibility a person has will depend on his or her level of influence or control. This concept is recognised in law. 2. All Managers The following responsibilities are established in law and are the general responsibility of all management staff. In addition to the general duties, specific responsibilities also apply. It is managements responsibility to ensure that those issues that they cannot directly control are passed onto the relevant person or persons. All managers shall, as far as it is practicable, provide and maintain a working environment in which staff, students and others are not exposed to hazards and shall

provide and maintain workplaces, plant and systems of work such that as far as practicable, staff, students, contractors and others are not exposed to hazards provide such information, instruction, training and supervision of staff and students as is necessary to enable them to perform their work in such a manner that they are

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Mr.Channabasappa.K.M PCON not exposed to hazards consult and co-operate with safety and health representatives, employees and others at the workplace regarding safety and health issues where it is not practicable to avoid the presence of hazards at the workplace, provide staff and students with such adequate personal protective clothing and equipment as is practicable to protect them against those hazards, without any cost to the staff and student (as appropriate) make arrangements for ensuring that, so far as practicable that the use cleaning, maintenance, transportation and disposal of plant; and the use, handling, processing, storage, transportation and disposal of substances at the workplace is carried out in a manner such that staff, students, contractors and others are not exposed to hazards

3. Deans, Heads of Schools, Directors of Centres / Sections In addition to the general responsibility placed on all managers, Deans, Heads of Schools, Directors of Centres / Sections are also responsible for the following within their work areas

Establishing local policy and management of safety and health Regularly evaluating and reviewing occupational safety and health performance indicators for the work area Appointing and supporting the necessary safety personnel Allocating the necessary resources to the safety and health program Devising and implementing priority plans to address concerns that cannot be resolved immediately Ensuring all staff are adequately trained and competent, with respect to safety and health, for the tasks undertaken Ensuring all staff, students (as applicable) and others (as applicable) undertake a thorough safety induction upon commencement of employment or duties Ensuring that supervisory staff are aware of and act upon their responsibilities Ensuring the proper supervision of staff, students and others Ensuring staff and students are aware of the reporting and resolution process for hazards, incidents and injuries Establishing local safety and health consultation and information arrangements Establishing and actively supporting a local Safety Committee Annually reviewing the safety and health record of the work area, including occupational safety and health management plans, and issuing a statement of safety objectives for the following year Noting all incident and injury reports, near miss reports, hazard reports, safety inspection reports and ensuring remedial action has been taken Keeping staff informed of safety matters, and ensure that procedures are in place to identify hazards, monitor and control risks and that systems are maintained and reviewed regularly Ensuring all necessary records are kept and maintained up to date Cooperating with the rehabilitation of injured and sick employees in accordance with the Universitys injury management policy Ensuring compliance with legislations, University safety and health policies, procedures and guidelines

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4. Safety Committees Faculties/Schools/Centres and Sections are strongly encouraged to systematically address safety and health matters through effective Safety Committees involving representatives from senior management, staff (academic, general), safety and health representatives and students. Suggested agenda items for these Committees are

hazards reported and actions arising incident/injuries and lost time follow ups workers' compensation support (as necessary) safety related training (including inductions) workplace inspections and follow ups implementation of University, Faculty and School safety related policies, procedures, and guidelines safety budgets and funding promotion of a workplace safety culture preparing for workplace audits and submitting for recognition of achievements (eg UWA Safety Awards)

5. Supervisors Supervisors are those who have responsibility for the control of other persons within a work area or part of a work area of a Faculty/School/Centre/Section. In addition to the general responsibilities, supervisors are also responsible for

ensuring that all staff supervised within their area are aware of their responsibility to work and act safely conducting regular safety inspections conducting and reporting incidents, injuries or near miss reports and/or investigations and ensuring corrective action is taken as necessary making training recommendations, as they see necessary, to the Faculty/School/Centre/Section heads ensuring the proper induction of new staff, following University guidelines cooperating in the rehabilitation of injured employees cooperating in the implementation and administration of the University safety and health policies, procedures and guidelines

6. University employees, undergraduate and post-graduate students All employees and students are responsible for working and acting safely. Specific responsibilities include

taking reasonable care of their safety and health and that of co-workers, students and visitors cooperating with the implementation and administration of University safety policies, procedures and guidelines observing all instructions and rules issued to protect their safety and health and that of others using plant and equipment as instructed by their supervisor making proper use of all safeguards, safety devices, personal protective equipment

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Mr.Channabasappa.K.M PCON and other appliances for safety purposes using protective equipment and wearing personal protective clothing as instructed seeking information or advice regarding hazards and procedures where necessary before carrying out new or unfamiliar work being familiar with emergency and evacuation procedures and the location of first aid kits, personnel and emergency equipment, and if appropriately trained, using emergency equipment reporting all incidents, injuries, near misses and hazards to their supervisor

7. Safety and Health Representatives The functions of a safety and health representative are, in the interests of safety and health at the workplace for which they are elected

to inspect the workplace or any part of it at such times as agreed with the Faculty/Department/Centre/Section heads immediately, in the event of an accident, a dangerous occurrence, or a risk of imminent and serious injury to, or imminent and serious harm to the heath of any person to carry out any appropriate investigation in respect of the matter to keep informed on the safety and health information provided by the University in accordance with the Occupational Safety and Health Act forthwith to report to the immediate supervisor any hazard or potential hazard to which any person is, or might be, exposed at the workplace that comes to his/her notice to refer any matters that he/she thinks should be considered by the local Safety Committee or the University Safety Committee to consult, cooperate and liaise with staff or students regarding matters concerning the safety, health and welfare of persons in the workplace

8. School Safety Officers The role of School Safety Officers is to assist Heads of Schools and Directors of Centres /Sections and supervisors in fulfilling their safety and health related responsibilities. Specific responsibilities include

Assisting with a management systems approach to safety and health within the School / Centre /Section Assisting with the appointment of safety personnel and ensuring they understand and fulfil their responsibilities Coordinating their activities with those of other safety personnel such as Safety and Health Representatives, First Aid Officers, Building Wardens, Wardens and designated School or Section Safety Officers (Biological, Chemical, Fieldwork, Radiation) Conducting or coordinating regular internal safety inspections Discussing potentially hazardous processes and operations with staff, students and visitors and obtaining their cooperation in reducing them as much as possible Informing Heads of Schools and Directors of Centres/Sections in writing of remaining hazards (responsibilities for carrying out risk assessments lies with the staff member in control of the operation) Familiarising themselves with any Statutory or University regulations, policies and

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procedures which would normally be applicable and informing their Head of School in writing in cases where this is not done Periodically inspecting hazard, incident and injury reports, investigating where appropriate, and taking appropriate action to achieve safe working and prevent recurrences Recommending to the Head of School any changes to avoid hazards (the responsibility for implementing such recommendation rests with the Head of School) Informing others of possible hazards by distribution and circulation of safety information and by appropriate publicity e.g. circulars, posters

9. Wardens The evacuation of buildings may be required in the event of fires, major spills, bomb threats or earthquakes. Heads of School are primarily responsible for ensuring evacuation procedures are developed and enforced within their work areas. Wardens are responsible for assisting in the planning and the actual execution of building evacuations. Wardens are required to be familiar with recognising and responding to alarms, ensuring the building is evacuated, ensuring that all personal can be accounted for and for liasing with the support services which are required to attend to the alarm. Each building should have a Building Warden and a number of Wardens for areas within the building. It is essential that there be deputy wardens to assist and in case of absences. 10. First Aid Officers Nominated First Aid Officers have current Senior First Aid Certificates and have skills in basic first aid as well as more complex life saving techniques such as expired air resuscitation and cardio-pulmonary. First Aid Officers are required to be familiar with the specific hazards and conditions of their workplace. 11. Contractors Contractors includes principal contractors and their sub contractors, who may be engaged by UWA Facilities Management, Faculties, Schools or Sections for construction, building and infra-structure maintenance and repair, communication installations and deliveries on campus. Contractors are required to comply with the UWA Contractor Safety and Health policy and are responsible for:

Ensuring their staff are properly qualified and trained to safely undertake the work Ensuring they and their staff are properly inducted to UWA specific standards Submitting a completed Risk Management Checklist with proof of insurances Submitting a Safety Management Plan for larger contract works Obtaining permits to work as required prior to commencing any hazardous work such as hot work, asbestos removal, demolition, confined spaces or electrical work.

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Mr.Channabasappa.K.M PCON 12. Visitors Visitors are responsible for cooperating with University safety and health requirements and not interfering with any aspects of the safety and health management systems on campus. 13. UWA Safety and Health The role of UWA Safety and Health is to develop, advise on and assist in the implementation of the University's Occupational Safety and Health policy. This is achieved through

developing and implementing occupational safety and health policies, plans and procedures effective workplace consultation conducting hazard identification, risk assessment and control providing safety information and training

The primary responsibility for safety and health for employees, students, contractors and visitors rests with the University's line management. UWA Safety and Health provides corporate services for Faculties, Schools, Centres and Sections to assist them in complying with legislation requirements and best safety practices. Services that are provided include

emergency planning and response insurance - property, liability, motor vehicle, travel and student accident plan workers' compensation and rehabilitation manual handling and ergonomic assessment biological, chemical, radiation, laboratory and workshop safety hazard, incident and injury investigation safety information and training workplace visits and inspections

UWA Safety and Health provides the executive support for the University's central safety committees which have been set up under legislation or similar obligations. The Office is responsible to the Director, Human Resources. 14. UWA Facilities Management Facilities Management Senior Managers in Planning and Design and Operations and Maintenance are responsible for ensuring all University building structures and infrastructure services and equipment comply with all statutory regulations, Australian Standards and Codes of Practice requirements for OSH, environment, public health, Commonwealth Gene Technology legislation and local government authorities. 15. Security and Parking The Security and Parking Offices role is to monitor and assist with the personal safety of staff, students and visitors whilst on campus and to provide services to protect personal security such as night transport, security officers and barriers. They are also

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responsible for

providing a first aid response service to the campus coordinating the emergency response to fires, bomb threats, explosions, gas leaks, storms and other dangerous incidents determining parking policy on campus including placement of barriers and signs in shared pedestrian/vehicle zones.

16. University Safety Committee The University Safety Committee comprises of elected Safety and Health Representatives and representatives from University management. The purpose of the committee is to provide a forum for safety and health issues to be discussed and to make recommendations at a senior level. Reporting to the University Safety Committee is a number of specialist safety subcommittees including

Chemicals and Carcinogen Committee Emergency Planning Committee Institutional Biosafety Committee Radiation Safety Committee Ventilation Committee

17. Breach of conduct or discipline Any misuses or interference with safety equipment or measures put in place to protect the safety and health of staff, students and others will not be tolerated, and those identified as misusing or interfering with safety equipment or measures will be dealt with as a breach of conduct or discipline

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Mr.Channabasappa.K.M PCON

6. INFECTION CONTROL & STANDARD SAFETY MEASURES

INTRODUCTION Hospital infection is also called Nosocomial infection.It is the single largest factor that adversely affects both the patient and the hospital.The English word Nosocomial is derived from the Greek NOSOKOMEION meaning hospital. Nosocomial infection is that which develops in the patients after more than 48 hours of hospitalization. Bacterial infections, which appear within first 48 hours of admission, are considered as community acquired.

OBJECTIVES:
At the end of the class the students will be able to: Define infection Understand the chain of infection Know about medical and surgical sepsis Know the preventive measures of infection.

TERMINOLOGIES:

Nosocomial infection: Hospital acquired infection Fumigation: use of gases or vapours to bring about disinfestations of clothings, buildings etc. Vector: an animal or an insect which transmits parasitic microorganism.

DEFINITION OF INFECTION: Injurious contamination of body or parts of the body by bacteria, viruses, fungi, protozoa and rickettsia or by the toxin that they may produce Infection may be local or generalized and spread throughout the body. Once the infectious agent enters the host it begins to proliferate and reacts with the defense mechanisms of the body producing infection symptoms and signs: pain, swelling, redness, functional disorders, rise in temperature and pulse rate and leucocytosis BASICS OF INFECTION CONTROL Prevention of nosocomial infection is the responsibility of all individuals and services provided by healthcare setting. To practice good asepsis, one should always know: what is dirty, what is clean, what is sterile and keep them separate. Hospital policies & procedures are applied to prevent spread of infection in hospital PRINCIPLES Client safety in the health care environment requires the reduction of microorganism transmission. Infection control practices are directed at controlling or eliminating sources of infection in the health care agency or home. Nurses are responsible for protecting clients and themselves by using infection control practices. Nurses and clients must be educated on the types of infections, modes of transmission, risks for susceptibility, and infection control practices required to control or prevent further transmission.

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CHAIN OF INFECTION The chain of infection describes the phenomenon of developing an infectious process. There must be an interactive process that involves the agent, host, and environment. This interactive process must involve several essential elements, or links in the chain, for transmission of microorganisms to occur. The six essential links (elements) in the chain of infection. Without the transmission of microorganisms, an infectious process cannot occur. Therefore, knowledge about the chain of infection for an infectious process permits control or elimination of the microorganism by breaking the links in the chain of infection. Breaking the chain of infection occurs by altering the interactive process of agent, host, and environment, as shown

Breaking the Chain of Infection Nurses focus on breaking the chain of infection by applying proper infection control practices to interrupt the mode of transmission. The chain of infection can also be broken by interrupting or blocking the agent, portal of exit, or portal of entry or by destroying the agent or decreasing the hosts susceptibility. Refer to Figure 31-3, which shows preventive measuresthatbreakthechainofinfection.

Modes of Transmission The mode of transmission is the process that bridges the gap between the portal of exit of the biological agent from the reservoir or source and the portal of entry of the 100

Mr.Channabasappa.K.M PCON susceptible new host. Most biological agents have a primary mode of transmission; however, some microorganisms may be transmitted by more than one mode. Almost anything in the environment can become a potential means of transmitting infection, depending on the agent. The most important and frequent mode of transmission is contact transmission, which involves the direct physical transfer of an agent from an infected person to a host through direct contact with a contaminated object or close contact with contaminated secretions. Sexually transmitted diseases are examples of diseases spread by direct contact. Airborne transmission occurs when a susceptible host contacts droplet nuclei or dust particles that are suspended in the air. Vehicle and vectorborne transmission are indirect modes of transmission, because transmission occurs by an intermediate source. Vehicle transmission occurs when an agent is transferred to a susceptible host by contaminated inanimate objects such as water, food, milk, drugs, and blood. Vectorborne transmission occurs when an agent is transferred to a susceptible host by animate means such as mosquitoes, fleas, ticks, lice,and other animals.

SURGICAL ASEPSIS Commonly used disinfectants and germicides Bacillocide: - it contains formaldehyde, glutaraldehyde, alkylurea derivatives and benzalkonium chloride. Use 2% solution by dissolving 200ml of the concentrate in 10 litres of water. It is used for disinfecting surfaces and for spraying rooms. The fans and air conditioners should be put off for 30 minutes and surfaces should be kept wet with bacillocide for 30 minutes for good efficacy. Korsolex:- it contains formaldehyde and glutaraldehyde. One part of the concentrate is mixed with 9 parts of water to prepare 10% solution. For disinfection the solution should remain in contact for 20 minutes and for sterilization for 4 hours. Cidex: - it is a 2% solution of flutaraldehyde with an activator. The solution should remain in contact for 20 minutes for disinfection and 4 hours for sterilization. Savlon: - it is a mixture of cetrimide, chlorhexidine gluconate and isopropyle alcohol. Use 1:100 solution for equipments and furniture and 1:30 solution for treating dirty wounds and disinfecting catheters or thermometers. Sterilium: - it contains 2- propanolol, 1- propanolol, and ethyl hexadechyle dimethyl ammonium ethyl surfate. Rub 2- 3ml of sterilium on the palms and backs of the hands for 30 seconds and allow it to dry, for disinfection of hands. It can be used in between nursing care or after handling the babies. It should not replace thorough hand washing before entering the NICU. Betadine: - it is 7.5% solution of povidone iodine and used for preparation of skin and disinfection of wounds. For skin preparation, leave it to dry for 60 seconds before undertaking the procedure. Formalin: - (40% formaldehyde aqueous solution) is used for fumigation. PREVENTION

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I.

Fumigation:-

In centers where excellent housekeeping and aseptic routines are maintained, fumigation does not provide any additional benefit. Doors, windows, walls and floors are scrubbed thoroughly with soap and water. The oxygen and central suction lines are shut off. The fans and air conditioners are put off. The ventilator outlets, air conditioner vents and gaps in doors and windows should be sealed airtight. For effective fumigation 30 ml of formalin (40%formaldehyde) in 90ml water is needed for a room of 30 cubic metres (1000 cubic feet) capacity. Formalin can be sprayed with the help of a vaporizer (Oticare) for 6 hours. After fumigation, the doors and windows are kept open till all the formalin fumes are allowed to escape. The left over formalin should be removed and 4-6 ounces of ammonium hydroxide is poured in the vaporizer which is plugged on for faster elimination of formalin fumes. When vaporizer is not available, formalin can be boiled or treated with 250 gm potassium permanganate and allowed to evaporate for 12 hours. Formalin should not be poured over the potassium permanganate as this may lead to explosion. II.Isolation:-

Isolation technique is intended to confine the microorganisms within a given and recognized area. There are number of isolation techniques and precautions used to prevent the spread of infection. Respiratory isolation Respiratory isolation is indicated in situations where the pathogens are spread on droplets from the respiratory tract. In this type of isolation, masks are generally worn by the nurses. Gowns are also worn when caring for small infants because of the possibility of drooling by the infants. When it is possible clients are taught to cover their noses and mouths with several layers of tissue paper or handkerchief. If tissue paper is used they should be disposed properly. Restrict the number of visitors. Precautions must be taken while collecting the sputum specimens from the clients. The nurse suffering from respiratory diseases should not attend to the client. Enteric isolation Enteric isolation is indicated when the pathogens are admitted in the faeces. For this type of isolation it is not necessary to wear a mask, but it is recommended that gloves and gowns be worn while handing soiled articles. Thorough hand washing should be emphasized both by the clients and nurses. The soiled articles such as linen should be disinfected before it is sent to dhobi. Wound and skin isolation This type of isolation is for pathogens which are found in wounds and can be transmitted by the contact with the wounds or by contact with the articles contaminated with the wound discharges. Usually gowns and gloves are worn in this type of isolation. Important point to note is the safe disposal of dressings and discharges from the wounds and the disinfection of articles. Strict isolation techniques should be followed while caring for clients with abscesses, boils, infected burns, gas gangrene anthrax, rabies, tetanus, veneral diseases, scabies etc. all the articles used for these clients should be kept separate. Great care should be taken by the nurses to prevent the cuts or abrasions on their hands. Frequent and thorough washing reduces the chances of infection.

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Mr.Channabasappa.K.M PCON Blood isolation This type of isolation is intended to prevent transmission of pathogens that are found in the blood. Therefore, any equipment that comes in contact with the clients blood should be carefully disinfected before touching another object or person. Use of mosquito nets are also emphasized to prevent this type of infection. III) BARRIER PROTECTION: Materials that protect the health care worker from infection. Gloves Mask Apron Eyewear Footwear

1. Gloves All skin defects must be covered with water proof dressing Use well fitting, disposable / autoclaved Change if visibly contaminated / breached Remove before handling telephones, performing office work, leaving workplace 2. Mask & Goggles Facial protection When splashing or spraying of blood / blood fluids expected 3. Apron Gowns/Special uniforms in high risk areas 4. Foot wear Feet should be well covered on all sides, especially while working in areas where spillage of infectious material is common, like operation theatres, labour room, laboratories. Soft shoes are preferred to sandals.

IV.HAND WASHING: Protects both health personnels and patients . The main forms are: a) Social handwashing Done for simple cleaning of hands with soap and water. Reduces the transient flora. A modification is careful handwashing which is done immediately after touching a patient or after contamination. All areas of the hand upto the wrist are cleaned by rubbing for at least 2 minutes. b) Hygienic hand disinfection After social hand washing, to get a more sustained effect, especially while caring for infected patients in special care units like ICUs and neonatal units. 70% ethyl alcohol hand disinfectants may be rubbed thoroughly over the hands. This effectively kills all transient flora, the action is fast and short-lived, hence has to be repeated after touching each patient. c) Surgical hand disinfection Preoperative washing hands by surgeon. Done with antibacterial soap e.g containing chlorhexidine or an iodophore, followed by 70%alcohol rub. Hands are scrubbed thoroughly for 5-10 minutes upto the elbows, taking care to scrub nails and interdigital areas.

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PREVENTION OF CROSS INFECTION

Cross infection refers to the transmission of a pathogenic organism from one person to another. It is a common and important mode of infection with many varieties of organisms, including streptococcal and other bacterial diseases, viral hepatitis A and some other fecal-oral infections, such as scabies, fungus infections, pinworms, and roundworms. The preventive measures include constant surveillance, maintenance of sanitary conditions, and prompt intervention whenever an infection is detected. The best way to prevent cross infections is by rigorous observance of personal hygiene at all times, and through the use of barrier nursing, sanitary practices, and other pertinent procedures. HOSPITAL WASTE MANAGEMENT Hospital waste is Any waste which is generated in the diagnosis, treatment or immunization of human beings or animals or in research in a hospital. Colour codes and type of containers used for disposal of biomedical waste are as follows: Colour coding Yellow Type of Container Waste Category Treatment options Deep

Plastic Bags

Human and animal wastes, Microbial and Biological wastes Incineration/ andsoiledwastes Burial Microbiological and Biological Autoclave/ wastes, Soiled wastes, Solid PlasticMicrowave/ Chemical wastes Autoclave/ Treatment) bag, Waste sharps and solid waste Microwave/ Chemical proof Treatment Destruction and Shredding Discarded medicines, Cytotoxic drugs, Incineration ash and Disposal in secured chemicalwaste land fills

Red

Disinfected container/ bags

Blue/Plastic White/Puncture Transparent container

Black

Plastic bag

General waste such as office Disposed in secured waste, food waste & garden landfills waste HOSPITAL INFECTION CONTROL PROGRAMME The main aim of the hospital infection programme is to lower the risk of an infection during the period of hospitalization. THREE ASPECTS : Development of an effective surveillance system to know the risk of nosocomial infection. Green Plastic Container Development of policies and procedures to reduce risk of nosocomial infections.

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Mr.Channabasappa.K.M PCON Maintenance of continuing education programme from hospital personnel BASIC ELEMENTS: Providing a system of identification and reporting of infections and providing a system for keeping records of infections Providing for good hospital hygiene ,aseptic technique and sterilization and disinfection practices. Providing for personnel orientation and continuing education programme in infection prevention and control . Providing for co-ordination with all departments and with medical/ nursing audit committee in quality assurance. Responsibility of hospital administrator/head of health care facility The hospital administrator/head of hospital should: Provide the funds and resources for infection control programme Ensure a safe and clean environment Ensure the availability of safe food and drinking water Ensure the availability of sterile supplies and material, and Establish an infection control committee and team.

INFECTION CONTROL ORGANIZATIONS IN A HOSPITAL Infection control organizations are essential features of an infection control programme. These organizations are: 1. Infection Control Team (ICT) Each hospital will be having their own infection control team and committee. The infection control team includes three main posts they are 1. Chairperson- He is the head of the infection control team. The designation of chairperson is he/she should be registered doctor may be microbiologist. 2. Coordinator- He is the member of infection control team. The designation of the coordinator should be registered doctor, HOD of surgery and medicine preferably may be HOD of other department. 3. Surviellent- He/she may be the Nursing superintendent of that hospital

Functions of infection control team Detects, investigates nosocomial infections. Investigation of environmental problems related to hospital infection. Detects community acquired infections in the hospital and refers to the appropriate authority for follow-up. Prompts initiation by physicians of hospitals infection report. Assist in development and review of infection control procedures, to be forwarded to the central committee annually. Monitoring the hospital policy compliance on isolation procedures. Development and implementation of inservice orientation program related to infection control. Monitoring the effectiveness of infection control programs. Guiding and monitoring of hospital infection through the cleaning department company, catering division, water supply department and other environmental.

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2. Infection Control Committee (ICC) The infection control committee includes all the in charge staffs of all the department of hospital like medical, nursing, paramedical, class four workers etc. The infection control officer is the member secretary. The committee meets regularly and not less than three times a year.

FUNCTIONS OF ICC The committee will: Conduct periodical review of statistics on nosocomial infections. Carry out evaluation of routine surveillance activities including reports on bacteriological swab counts of critical areas surveyed. Supervise epidemiological investigations. Review current policies. Convey infection control information to hospital staff.

3.

Infection Control Officer (ICO)

The Infection Control Officer is usually a medical microbiologist or any other physician with an interest in hospital associated infections. Functions 1. Secretary of Infection Control Committee and responsible for recording minutes and arranging meetings; 2. Consultant member of ICC and leader of ICT 3.Identification and reporting of pathogens and their antibiotic sensitivity; 4. Regular analysis and dissemination of antibiotic resistance data, emerging pathogens and unusual laboratory findings; 5.Initiating surveillance of hospital infections and detection of outbreaks; 6.Investigation of outbreaks, and 7. Training and education in infection control procedures and practice.

4. Infection Control Doctor (ICD)

The ICD must be a registered medical practitioner. In the majority of countries, the role is performed either by a medical microbiologist or hospital epidemiologist. Hospital consultants in other disciplines (e.g. infectious diseases) may be appointed. Irrespective of their professional background, the ICD should have knowledge and experience in asepsis, hospital epidemiology, infectious disease, microbiology, sterilization and disinfection, and surveillance. It is recommended that one ICD is required for every 1,000 beds.

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Mr.Channabasappa.K.M PCON Role and responsibilities of the ICD Serves as a specialist advisor and takes a leading role in the effective functioning of the ICT. Should be an active member of the hospital Infection Control Committee (ICC) and may act as its Chairman. Assists the hospital ICC in drawing up annual plans, policies and long-term programmes for the prevention of hospital infection. Advises the chief executive/hospital administrator directly on all aspects of infection control in the hospital and on the implementation of agreed policies. Participates in the preparation of tender documents for the support services and advises on infection control aspects. Is involved in setting quality standards, surveillance and audit with regard to hospital infection.

5.

Infection Control Nurse (ICN)

The day-to-day activities of surveillance can be best handled by a sufficiently senior and experienced full-time nurse, with special training in hospital infection control activities. In very large hospitals, there should be atleast one infection control nurse for every 250 beds.

TASKS OF INFECTION CONTROL NURSE She directly reports to the infection control officer (ICO) and briefs him every day on occurrence of a case and related matters. Early and complete reporting is the sheet anchor of any hospital infection control programme. Therefore, the infection control sister must be authorized to report any actual or suspected infection immediately, to initiate a culture and sensitivity test, institute appropriate isolation procedure if it is so requires, and notify the physician incharge of the patient. She should also have direct access to the hospital administrator on matters of serious breaches of control practices discovered by her.

Her activities will include the following. 1. Daily visit to all wards and patient holding units. 2. Checking ward sisters report register for tell-tale records suggestive of infection. 3. Collection and tabulation of daily data of incidence of hospital infection. Recorded data of all infections should include the identification and location of the patient, the type of infection, the cultures taken and the results (when known), any antibiotics administered, and the identity of the physician responsible for the care of the patient. 4. Ensuring that the samples of blood, stool, sputum, urine, swab- are collected and despatched to the laboratory in time. Laboratory records are an important surveillance tool and data source.The data is gathered by the infection control nurse during ward rounds. 5. Initiating the hospital infection control form while documenting for nosocomial infections, the registration form used should be different from the routine investigation forms, so that minimum time is wasted in getting the culture and sensitivity reports. 6. Compilation of wardwise, desciplinewise or procedurewise statsistics. 7. Daily visit to laboratory to ascertain results of previous days samples. 8. Monitoring and supervision of the infection among hospital staff. 9. Training of nursing aides and paramedical personnel on correct use of hygiene practices and aseptic techniques. 10. Assist in bacteriological studies of all cases.

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6.

Infection Control Manual (ICM)

It is recommended that each hospital develops its own infection control manual based upon existing documents but modified, for local circumstances and risks

EFFECTIVE CONTROL MEASURES 1. People It is the people in hospitals rather than the physical environment which constitutes the reservoir of infection.Nurses should follow hand washing techniques properly and they should also guide other staffs, students to follow the procedure of hand washing which includes social handwashing, followed by procedural hand wash. All the steps of hand washing should be followed properly. Following the habit of procedural hand wash after touching each child will helps to prevent cross infection. Always use liquid soap instead of solid soap for hand washing 2. Aseptic Techniques Strict adherence to aseptic techniques in various invasive procedures. Insertion and removal of catheters, surgical tubings, drainage tubes and packs need strict notouch techniques even while they are done outside of operation theaters in nursing units. 3. Segregation of contaminated Instruments There must be a system for keeping the contaminated pieces of linen, sputum cups, bedpans, urinals, and similar items separately to minimize chances of getting mixed up with clean items.
4. Isolation policy

Availability of adequate number of trained nurses is crucial for prevention of nosocomial infection. Isolation facilities for patients with communicable diseases and those vulnerable to infection. Such facilities must be made available in ICU, nurseries, burn unit, transplant unit, etc. Strict control on wearing of mask, gown and gloves must be exercised while attending to such patients. All articles taken for patient use must be treated appropriately. 5. Masking and Gowning and Glowing Gloves should be worn especially while dealing with HIV infected patients.. As for any surgical procedure lumbar puncture Gown and Glove should be worn by the person who conducts the procedure. Gowns should be washed and Autoclaved daily. 6. Disinfection Practices Different kinds of disinfectants vary in their reaction to different kinds of microorganisms. Phenolic compounds are active against gram-negative organisms. Quaternery ammonium compounds against staphylococci, streptococci, and lodophores and hypochlorites have a broad spectrum of action. Selection of appropriate disinfectant for different purpose is important. The following should be checked.

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Mr.Channabasappa.K.M PCON Appropriate choice Appropriate concentration Appropriate contact time Appropriate method of use

7. Sterilisation Practices An efficient CSSD ensures supply of properly sterilized articles to all users in the hospital. Each sterilisation must be monitored through the use of heat- sensitive tapes. All steam and ethylene oxide sterilizers should be checked atleast once each week with a suitable live spore preparation by the laboratory. Instruments which come in contact with mucous membranes but are disinfected rather than sterilized before use, such as endoscopes, and anaesthesia equipment may be bacteriologically sampled on a spot check basis to ensure adequacy of disinfetion.

8. Prevention of Injuries. After using the disposable needles, never recap them to potential risk of injury they should be disposed off uncapped. Injection files and cotton swabs should be used for breaking ampoules. Scissors and blades should be handled with extreme care. Needles should never be left on the bed, table, chair, nurses station etc. Heavy duty gloves should be used while handling and washing sharp instruments and glass ware.

Post exposure protocol for needle stick injury Dont panic. Dont squeeze the injured site Wash with soap and water immediately. Report to the casualty and provide proper history of exposure for immunization.

Post exposure protocol regimen for HIV (Basic regimen) Zidovudine [There is risk for79% of infection] (Expanded regimen) It goes for 28 days + basic regimen

Post exposure prophylaxis regimen for Hepatitis infection If vaccinated no problem. If not vaccinated previously take Immunoglobulins immediately then take hepatitis vaccine regimen for 6 months.

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9. Outpatient Department In outpatient department separate arrangements for receiving and examining patients suspected of having significant acute communicable condition should be made.

10. Dietary service Storage of food articles and appropriate temperatures in refrigerators and deep freezers must be checked. Control of rodents and insects is a must to prevent contamination of stored food and supplies Fruits and vegetables eaten raw must be thoroughly washed before consumption.

11. Handling the laboratory specimens The specimens should be collected in screw capped plastic disposable container without soiling laboratory forms. Never pipette blood or other body fluid with your mouth.

12. Handling the blood spills The spill should be covered with cotton, news paper or other absorbent material. Pour 1% of Hydro chlorate solution or bleach solution over the spill Wipe the spill soaked area after 20 minutes. Discard the soiled materials in a polythene lined waste bag(red bag) The soiled floor should be cleaned with the detergents.

13. Housekeeping routines Dry dusting and sweeping should be avoided; it is preferable to vacuum cleaner to suck the dust from the floor, walls and equipments. Wet mopping of floors with soap and water containing 3% phenol should be carried out at least thrice daily The waxing of surfaces and use of oil in water for mopping may limit dissemination of microorganisms. The walls should be wiped or sprayed with 2% bacillocide once a week The sinks should be washed with 3% phenol or 5% Lysol at least once a day.

14. Air hygiene in operation theaters Clogging of air filters of the AC system renders the ventilation in operation theaters and such other areas infective. Air filters should be frequently cleaned. Periodical smoke studies should be carried out for air movement in operation theaters and checking that the AC system is achieving the desirable number of air changes per hour. 15. Termination Disinfection Termination disinfection of isolation rooms must be carried out thoroughly on the principle as operating rooms before permitting the room for reuse. At such times,

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Mr.Channabasappa.K.M PCON the staff must use the same precautions (cap, mask, gown, gloves) used for nursing in such isolation rooms. 16. Developing a sense of awareness Developing in all hospital workers a high sense of awareness, and training and retraining in the precautionary measures, prevention and control. 17. Prevention of occupational exposure Cover all the cuts and abrasions with water proof dressings. Use gloves when handling instruments or equipments. Do not recap needles after use Never manipulate any sharp that involves directing the point of the needle towards any part of the body. Disposal sharps immediately. Refer to the needles stick injury guidelines. Health care workers with skin condition must seek the advice of occupational health nurse. Advice junior staffs and students to inform to seniors to be reported for any sign of occupational exposure. 18. Management of patient care equipments Don not re use single patients equipments to other patients. Patient care equipments should be decontaminated as per the decontamination policy. Wear protective clothings when handling the contaminated articles. Do not use single use equipments again Patient related equipments such as pumps, Drip stands etc must be kept clean. 19. Waste disposal Nurses should have thorough information and knowledge regarding Biomedical and general waste management. There should be provision for foot operated bins adjacent to each baby unit for disposal of used materials and soiled linens Plastic bags should be kept as hampers in the dust bins and they should be sealed before their removal. The dust bin should be mopped with 3% of phenol every day. To have supervision over segregation of waste in appropriate color bags according to CDC recommendations Knowledge and practice regarding transportation of waste should be essential.

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EXAMPLE: POLICY GUIDELINES RELATED TO INFECTION CONTROL Recommended Standards This set of standards, adapted mainly from Guidelines for Perinatal Care, 4th Edition by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, focuses on the following areas:I. Physical Setup II. Administrative arrangement I. Physical Setup (with additional reference to Recommended Standards for Newborn ICU Design by The Committee to Establish Recommended Standards for Newborn ICU Design1

Space 1. Each infant care space in the Neonatal Intensive Care Unit shall preferably contain a minimum of 11.2 square meters (120 square feet), excluding sinks and aisles 2. There shall be an aisle adjacent to each infant care space with a minimum width of 0.9 meters (3 feet).3. Traffic to other services shall not pass through the unit Ventilation. 1. A minimum of 6 air changes per hour is required for the NICU, with a minimum of 2 changes being outside air. 2. The ventilation pattern shall inhibit particulate matter from moving freely in the space and intake and exhaust vents shall be situated as to minimize drafts on or near the infant beds. 3. Ventilation air delivered to the NICU shall be filtered with at least 90 % efficiency.

4. Fresh air intake shall be located at least 7.6 meters (25 feet) from exhaust outlets of ventilating systems, combustion equipment stacks, medical/surgical vacuum systems, plumbing vents, or areas that may collect vehicular exhausts or other noxious fumes. [IB] Scrub Areas 1. In the NICU, there should be at least 1 hands-free handwashing sink for 4 beds. 2. In single bedroom, a hands-free handwashing sink shall be provided within each infant care room. [II] 3. Handwashing facilities that can be used by children and people in wheelchairs shall be available in the NICU 4. Sinks for handwashing should not be built into counters used for other purposes 5. Sink location, construction material and related hardware (paper towel, covered trash receptacle, and soap dispensers) should be chosen with durability, ease of operation and noise control in mind6. Minimum dimensions for a handwashing sink are 61 cm wide X 41 cm front to back X 25 cm deep (24 in. X 16 in. X 10 in.) from the bottom of the sink to the top of its rim; so as to minimize splashing.7. Pictorial handwashing instructions should be provided above all sinks. 8. Sinks should be designed so as to control splashing and avoid standing or5 retained water.9. Faucet aerators may be useful to reduce water splashing in sinks, but they are notoriously susceptible to

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Mr.Channabasappa.K.M PCON contamination with a variety of hydrophilic bacteria. They should not be used. 10. Sinks should be scrubbed clean daily with a detergent. Air-borne Isolation Room(s) 1. Isolation rooms adequately designed to care for airborne infection should be available in any hospital with an NICU. In most cases, this is ideally situated within the NICU; but, in some circumstances, utilization of an isolation room elsewhere in the hospital would be suitable.2. An area for handwashing, gowning, and storage of clean and soiled materials shall be provided near the entrance to the room 3. Isolation rooms should have a minimum of 13.94 sq metre (150 square feet) of clear space, excluding the entry work area. Single and multibedded configurations are appropriate based on use. 4. Ventilation systems for isolation room(s) shall be engineered to have negative air pressure with air 100% exhausted to the outside. Air exhaust to outside the building do not need to be filtered but the exhaust vent needs to be away from air-intake vents, persons or animals. 5. A hands-free two-way emergency communication system is required within the isolation room to connect to the outside. 6. Remote physiologic monitoring of an isolated infant should be considered. 7. Isolation rooms should have observation windows with blinds for privacy. Choice and placement of blinds, windows, and other structural items should allow for ease of operation and cleaning.

II. Administrative arrangement Surveillance for Nosocomial Infection 1. With appropriate resources allocated from the hospital/ HAHO, the infection control committee of each hospital should work with perinatal care personnel to establish workable definitions of nosocomial infection for surveillance purposes, with particular reference to the definitions/ guidelines set out by this Working Group. 2. The definition selected should be applied consistently to allow uniform reporting and analysis of nosocomial infections 3. With appropriate resources from the Hospital/ HAHO, NICU personnel should cooperate with hospital infection control personnel in conducting and reviewing the results of surveillance programs for nosocomial infections in a confidential manner.

Prevention and Control of Infections Staff Health 1. Health care workers should be immune to rubella, measles and chicken pox 2. Yearly influenza vaccination is available 3. Ideally, individuals with a respiratory, cutaneous, mucocutaneous or gastrointestinal infection should not have direct contact with neonates. Handwashing 1. Medical and hospital personnel must follow careful hand-washing techniques to minimize transmission of disease 2. Personnel should remove rings, watches, and bracelets before washing their hands and entering the neonatal nursery.

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3. Fingernails should be trimmed short and no false fingernails or nail polish should be permitted. 4. Antiseptic preparations (e.g. chlorhexidine 4 %) should be used for scrubbing before entering the nursery, before providing care for neonates, before performing invasive procedures, and after providing care for neonates 5. Before handling neonates for the first time, personnel should scrub their hands and arms to a point above the elbow thoroughly with an antiseptic soap. After vigorous washing, the hands should be rinsed thoroughly and dried with paper towels. 6. A 10-second wash without a brush, but with soap and vigorous rubbing, followed by thorough rinsing under a stream of water, is required before and after handling each neonate and after touching objects or surfaces likely to be contaminated with virulent microorganisms or hospital pathogens. 7. Handwashing is necessary even when gloves have been worn in direct contact with the infant. Handwashing should immediately follow removal of gloves, before touching another infant. 8. Alcohol-containing foams kill bacteria satisfactorily when applied to clean hands and with sufficient contact (in accordance with manufacturers recommendations). They can be used in areas where no sinks are available or during emergency. [III] But they are not sufficient in cleaning physically soiled hands, because transient organisms are not removed.

Sibling Visits 1. Guidelines for visits should be established to maximize opportunities for visiting and to minimize the risks of nosocomial spread of pathogens brought into the unit by these young visitors. 2. No child with fever or symptoms of an acute illness, including an upper respiratory tract infection, gastroenteritis, or dermatitis, should be allowed to visit. Siblings who recently have been exposed to a known communicable disease and are susceptible should not be allowed to visit. These interviews should be documented in the patients record, and approval for each sibling visit should be noted 3. Children should carefully wash their hands before patient contact.

Dress Code 1. Dress codes should be established for regular and part-time personnel who enter the neonatal unit 2. Sterile long-sleeved gowns to be worn by all personnel who have direct contact with the sterile field during surgical and invasive procedures in the neonatal unit. 3. Gloves are to be worn when handling the neonate until blood and amniotic fluid have been removed from the skin. 4. When a neonate is held outside the bassinet by nursing or other neonatal intensive care unit personnel, a gown should be worn over the clothing and either discarded after use or maintained for use exclusively in the care of that neonate. If one gown is used for each neonate, the gowns should be changed regularly 5. Caps, masks and sterile gloves are to be used during surgical and invasive procedures. General Housekeeping 1. Cleaning should be performed in the following order patient areas, accessory areas and then adjacent halls 2. In the cleaning procedure, dust should not be dispersed into the air. 3. Standard types of portable vacuum cleaners should not be used in the neonatal ICU or SCBU because particulate matter and microbial contamination in the room may be

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Mr.Channabasappa.K.M PCON disturbed and distributed by the exhaust jet. Vacuum cleaners that discharge outside the patient care area (ie, central vacuum cleaning systems or portable vacuums) should be used so that only the cleaning wand, floor tool, and high-efficiency, particulate air filtered vacuum hose are brought into the patient care area. 4. Once dust has been removed, scrubbing with a mop and a disinfectant/detergent solution should be performed. Mop heads should be machine laundered and thoroughly dried daily. 5. Cabinet counters, work surfaces, and similar horizontal areas should be cleaned once a day and between patient use with a disinfectant/detergent and clean cloths; as they may be subject to heavy contamination during routine use. Friction cleaning is important to ensure physical removal of dirt and contaminating microorganisms. 6. Surfaces that are contaminated by patient specimens or accidental spills should be carefully cleaned and disinfected. 7. Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed periodically with a disinfectant/detergent solution as part of the general housekeeping program. 8. Sinks should be scrubbed clean at least daily with a detergent Cleaning & Disinfecting Patient Care Equipment Incubators, Open Care Units & Bassinets 1. When the incubators, open care units or bassinets are being cleaned and disinfected, all detachable parts should be removed and scrubbed meticulously 2. If the incubator has a fan, it should be cleaned and disinfected; the manufacturers instructions should be followed to avoid equipment damage. 3. The air filter should be maintained as recommended by the manufacturer. 4. Mattresses should be replaced when the surface covering is broken, because such a break precludes effective disinfection or sterilization 5. Portholes and porthole cuffs and sleeves are easily contaminated, often heavily; cuffs should be replaced on a regular schedule or cleaned and disinfected frequently with freshly prepared mild soap or disinfectant solutions 6. Incubators not in use should be thoroughly dried by running the incubator hot without water in the reservoir for 24 hours after disinfection 7. Infants who remain in the nursery for an extended period should be transferred periodically to a different, disinfected unit so that the originally occupied unit can be cleaned

Neonatal Linen clean and soiled Clean Linen 1. Procedures for laundering, making up packs and delivering linen to the nursery should be established by the medical, nursing, laundry and administrative staffs of the hospital 2. Each delivery of clean linen should contain sufficient linen for at least one 8-hour shift 3. Linen should be cleaned and transported in covered carts or laundry bags to the nursery areas 4. No new garments or linen should be used for neonates without prior laundering.

Soiled Linen 1. An established procedure for the disposal of soiled linen should be strictly Followed 2. Chutes for the transfer of soiled linen from patient care areas to the laundry are not acceptable unless they are under negative air pressure. 3. Soiled linen should be discarded into bags that prevent leakage.

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4. Sealed bags of reusable, soiled nursery linens should be taken to the laundry at least twice each day. 5. Impervious bags of soiled diapers (reusable or disposable) and other linen should be sealed and removed from the nursery at least every 8 hours. 6. All personnel should be aware that handling dirty diapers with bare hands can result in heavy contamination and transient colonization of the hands with microorganisms that cannot be easily eliminated with hand-washing and can be readily transmitted to the next neonate for whom they provide care.

Laundering: 1. The chemicals trichlorocarbanilide or sodium salt of pentachlorophenol should not be used in hospital laundering because they may be harmful. 2. To avoid the hazards associated with the use of such chemicals orenzymes in the hospital laundry, the physician in charge should be aware of all agents in use and should be informed before any changes are made in laundry chemicals or procedures. Caution should be exercised when new laundry or cleaning agents are introduced into the nursery or when procedures are changed.

Catheter-related sepsis 1. Meticulous attention should be given to aseptic insertion and maintenance of the cannula and to aseptic techniques of fluid administration. 2. All parenteral nutrition fluids should be mixed in the pharmacy, under a laminar flow hood. 3. If bottles of lipid emulsions are kept in the neonatal unit refrigerator, care should be taken to prevent contamination, as they are susceptible to contamination with a wide variety of bacteria and fungi that can proliferate to high concentrations within hours. Open bottles must be discarded no later than 24 hours after the seal has been broken. 4. Intravenous tubing, stopcocks, flush syringes should be changed CONCLUSION There is constant danger of patients admitted into the hospital getting infection while in the hospital.Ensuring a high standard of sterilization and disinfection to minimize the incidence of hospital infection has been the uppermost in the minds of clinicians as well as hospital administrators. BIBLIOGRAPHY 1. Sakharkar BM.Principles of Hospital Administration and Planning. 4th edition. NewDelhi : Jaypee Brothers Publishers(P) LTD;2006 2. Basavanthappa B.T. Nursing Administration. 2nd edition. Jaypee brothers. Delhi . 2009 3. Mrs.Joglekar . S. Kamal. Hospital Ward Management Professional Adjustments and Trends In Nursing.2nd edition.Bombay:Vora Medical Publications;1993 4. Francis.C.M, Mario C De Souza. Hospital Adminisration.3rd edition. NewDelhi : Jaypee Brothers Publishers(P) LTD;2004 5. Sharma Madhuri.Hospital Waste Management and its Monitoring.2nd edition. NewDelhi : Jaypee Brothers Publishers(P) LTD;2005 6. Goel. S.L, Kumar. R. Hospital Administration And Management.2nd edition.New Delhi:Deep & Deep Publications;2000 7. Jean Barrett.Ward Management and Teaching.9th edition.Delhi: Konark Publishers PVT LTD; 1997

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