Legal & Ethical Nursing

Nurse Practice Act & Scope of Practice

Your license, your practice, your legal boundaries — defined by your state's Nurse Practice Act.

The Nurse Practice Act (NPA)

• Each state has its own NPA — a set of laws that define the legal scope of nursing practice in that state
• Establishes requirements for licensure, education, and practice
• Defines what each level of nurse (LPN/LVN, RN, APRN) CAN and CANNOT do
• Enforced by the State Board of Nursing (BON)
• Violating the NPA can result in disciplinary action: reprimand, probation, suspension, or revocation of license

LPN/LVN Scope of Practice (General)

• CAN: Collect focused assessment data, reinforce patient teaching, administer medications (PO, IM, SubQ — IV varies by state), perform wound care and sterile procedures, insert urinary catheters, perform tracheostomy care, document and report findings, supervise UAPs/CNAs
• CANNOT (in most states): Perform initial comprehensive assessment, create or modify nursing care plans, provide initial patient/family education, administer IV push medications, receive telephone orders (varies), triage patients, manage unstable patients independently, perform blood transfusions (varies)

When in Doubt

• If you don't know whether a task is within your scope → DON'T DO IT until you verify
• Check your state's Nurse Practice Act, facility policies, and job description
• Performing outside your scope = grounds for disciplinary action and personal liability

Informed Consent

The patient MUST understand what they're agreeing to — and they have the right to refuse.

Elements of Informed Consent

• Diagnosis and reason for the proposed treatment
• Description of the procedure or treatment
• Expected benefits
• Material risks and potential complications
• Alternative treatments (including no treatment)
• The right to refuse or withdraw consent at any time

Who Obtains Consent?

• The physician/provider performing the procedure is responsible for explaining and obtaining informed consent
• The nurse's role is to: witness the patient's signature, verify the patient understands (if they have questions → notify the provider BEFORE the procedure), ensure the consent form is completed and in the chart
• The nurse does NOT explain the procedure or its risks — that is the provider's responsibility

Requirements for Valid Consent

• Voluntary — free of coercion or pressure
• Competent — the patient has decision-making capacity (alert, oriented, not under sedation or influence of drugs/alcohol). If incompetent → legal guardian or healthcare proxy consents.
• Informed — the patient understands the information provided
• Age of majority — typically 18 years old. Minors require parent/guardian consent EXCEPT: emancipated minors (married, in military, financially independent, court-declared), and emergencies.

Consent Exceptions

• Emergency: If the patient is unable to consent and there is an immediate threat to life → treatment can proceed under implied consent
• Emancipated minors: Can consent for themselves
• Mature minor doctrine: Some states allow minors to consent for STI treatment, contraception, substance abuse treatment, and mental health care without parental consent

Patient Rights

Every patient has these rights — and the nurse is obligated to protect them.

Key Patient Rights

• Right to informed consent — and the right to REFUSE treatment, even life-saving treatment (autonomy)
• Right to privacy and confidentiality — HIPAA protects patient health information
• Right to be treated with dignity and respect — regardless of race, religion, gender, sexual orientation, disability, or socioeconomic status
• Right to access medical records — patients can view and obtain copies of their records
• Right to know who is providing their care — introduce yourself, your title, and your role
• Right to pain management — adequate pain assessment and treatment
• Right to a safe environment
• Right to be free from restraints — unless medically necessary with proper orders and monitoring
• Right to have advance directives — and to have them honored
• Right to leave AMA (against medical advice) — if competent
• Right to an interpreter — for non-English-speaking patients. Family members should NOT serve as interpreters for medical discussions (use professional interpreters).

HIPAA & Confidentiality

Protecting patient information isn't just ethical — it's the law.

What HIPAA Protects

HIPAA (Health Insurance Portability and Accountability Act) protects PHI (Protected Health Information) — any information that can identify a patient and relates to their health, treatment, or payment. This includes: name, DOB, address, SSN, diagnosis, medications, lab results, photos, and even room number.

Common HIPAA Violations (Know These!)

• Discussing patients in public areas — elevators, cafeteria, hallways, parking lot
• Looking up records of patients you aren't assigned to — even out of curiosity. "Just looking" is a violation.
• Social media — posting ANY patient information, photos, or identifiable details on social media (even without names — if someone could identify the patient, it's a violation)
• Leaving computer screens visible — log off when stepping away. Position screens away from public view.
• Faxing or emailing PHI to the wrong recipient
• Sharing patient information with unauthorized family members — ask the patient WHO they authorize to receive their health information
• Discussing patient information with coworkers not involved in care
• Leaving patient charts or documents unattended

When CAN You Share Information?

• With the healthcare team directly involved in the patient's care (need-to-know basis)
• With the patient themselves
• With family/persons authorized by the patient
• When required by law (mandatory reporting — abuse, communicable diseases, gunshot wounds)
• For treatment, payment, and healthcare operations (TPO)

Malpractice & Negligence

Know the 4 elements — if any one is missing, malpractice cannot be proven.

Negligence vs Malpractice

Negligence

Failure to act as a reasonably prudent person would in similar circumstances. Unintentional. Example: anyone slipping on a wet floor they should have seen.

Malpractice

Negligence by a PROFESSIONAL (nurse, physician) that causes harm to a patient. Unintentional but involves professional standards. Example: a nurse giving the wrong medication because they didn't check the label → patient is harmed.

4 Elements of Malpractice (ALL Must Be Proven)

Examples of Malpractice

• Administering the wrong medication → patient has an adverse reaction
• Failing to assess a patient → deterioration goes unnoticed → patient is harmed
• Not reporting a critical lab value → delayed treatment → patient injury
• Failing to follow up on a provider order → patient doesn't receive necessary treatment
• Not documenting properly → continuity of care is compromised → patient harmed

Intentional Torts

Unlike malpractice (unintentional), these are deliberate acts.

Assault

Threatening or attempting to touch someone without consent — creating fear of harm. Nursing example: saying "If you don't take this medication, I'll hold you down and give you a shot" — no physical contact needed, just the threat.

Battery

Intentional, unauthorized touching of another person. Nursing example: performing a procedure without consent. Forcing medication on a competent patient who refuses.

False imprisonment

Unlawfully restricting a person's freedom of movement. Nursing example: using restraints without a proper order. Refusing to let a competent patient leave AMA.

Defamation

Making false statements that damage someone's reputation. Slander = spoken; Libel = written (e.g., documenting false information in the chart).

Invasion of privacy

Violating a patient's right to privacy. Examples: exposing a patient unnecessarily, sharing patient photos, allowing unauthorized visitors during care.

Fraud

Willful deception for personal gain. Examples: falsifying documentation, charting procedures that weren't done, falsifying credentials.

Mandatory Reporting

Nurses are mandatory reporters by law — failure to report can result in criminal charges.

What Nurses MUST Report

• Suspected child abuse or neglect — physical, emotional, sexual abuse or neglect. You do NOT need proof — suspicion is enough to trigger reporting. Report to Child Protective Services (CPS).
• Suspected elder abuse or neglect — physical abuse, emotional abuse, financial exploitation, neglect, abandonment. Report to Adult Protective Services (APS).
• Suspected domestic violence — varies by state. Document injuries objectively, offer resources, assess safety.
• Gunshot and stab wounds — report to law enforcement
• Communicable diseases — TB, HIV (varies by state), STIs, measles, hepatitis, and other conditions on your state's reportable list — report to the local/state health department (COVID-19 reporting now varies by state/facility policy)
• Impaired healthcare workers — a colleague who is using substances or is impaired and endangering patients → report to the supervisor/BON
• Unsafe staffing or conditions — if patient safety is at risk

Key Principles

• You do NOT need proof — reasonable suspicion is enough
• The nurse is protected from liability when reporting in good faith (even if the investigation finds no abuse)
• Failure to report can result in: criminal charges, loss of licensure, civil liability
• Document findings objectively: describe what you see (bruises, fractures, malnutrition) — do NOT interpret or accuse ("I suspect the parent did this" → WRONG. "Multiple bruises in various stages of healing noted on bilateral upper arms" → CORRECT)

Incident Reports & Documentation

What goes in the chart vs what goes in the incident report — they are NOT the same.

The Patient's Chart (Medical Record)

• Document WHAT happened, WHAT you observed, WHAT you did, and WHAT the patient's response was
• Be objective and factual — "Patient fell from bed at 0800. Found on floor at bedside. Alert, oriented, states 'I slipped.' VS stable. No visible injuries. Physician notified at 0805."
• Do NOT mention the incident report in the chart — the chart and the incident report are separate documents for different purposes
• Do NOT write "incident report filed" in the patient's chart

The Incident/Variance Report

• An internal document for quality improvement and risk management — NOT part of the medical record
• Completed for any unusual occurrence: falls, medication errors, equipment malfunction, needlestick injuries, patient or visitor injuries, near-misses
• Purpose: identify system problems, prevent future incidents, protect the facility legally
• Should be completed as soon as possible after the event
• Factual and objective — no blame, no opinions, no assumptions
• Submitted to risk management/supervisor per facility policy

AMA Discharge & Patient Refusal

Patients have the right to leave — and the right to refuse. Your job is to inform, not to force.

AMA (Against Medical Advice) Discharge

• A competent adult has the legal right to leave the hospital at any time, even if the healthcare team disagrees
• The nurse's role:

• You CANNOT physically prevent a competent patient from leaving — that would be false imprisonment
• If the patient is NOT competent (altered mental status, intoxication, psychosis) → additional steps may apply (psychiatric hold, safety protocols)

Patient Refusal of Treatment

• A competent patient can refuse ANY treatment — including life-saving treatment (autonomy)
• Nurse responsibilities: assess understanding, explain consequences, document the refusal and that teaching was provided, notify the provider
• Do NOT argue, coerce, or threaten — respect the patient's decision
• Continue to provide other aspects of care that the patient does accept

Key Laws & Legislation

The laws that shape nursing practice — know what each one requires.

Nurse Practice Act (NPA)

State law that defines the scope of nursing practice. Each state has its own. Defines what LPN/RN/APRN can do. Enforced by Board of Nursing. Violations = disciplinary action.

HIPAA (1996)

Protects patient health information (PHI). Patient data is confidential. Violations = fines + termination + possible criminal charges. PHI includes any identifying health info.

PSDA (1990)

Patient Self-Determination Act — requires healthcare facilities to ask patients about advance directives on admission. Facilities must: ask if patient has AD, provide AD info, document in chart. Does NOT require the patient to have one.

EMTALA

Emergency Medical Treatment & Labor Act — requires ERs to screen and stabilize ALL patients regardless of ability to pay. "Anti-dumping law." Cannot refuse emergency treatment or transfer unstable patients due to inability to pay or lack of insurance.

Good Samaritan Law

Protects healthcare providers who render emergency care in good faith outside their workplace. Applies ONLY in emergencies outside the healthcare setting (e.g., car accident, public collapse). Must act within competency. Does NOT apply to care provided at work.

Americans with Disabilities Act (ADA)

Prohibits discrimination based on disability. Healthcare facilities must provide reasonable accommodations (interpreters, accessible facilities, adaptive equipment).

Mandated Reporter Laws

Requires nurses to report suspected abuse/neglect. Failure to report = criminal liability. Good faith reporting is protected from lawsuits.

Frequently Asked Questions

Common student questions on this topic.

Quick-Reference Cheatsheet

Every key point from this guide on a single printable page.