LEGAL ETHIC OF

NURSING
PROJECT BASED LEARNING
TRIGGER FOR STANDARD PRACTICE IN NURSING

Group 1
1. Novita Eka Saputri
2. Achmad Vindo G
3. Dadang Putrawansyah
4. A. Zahriar Badaruddin
5. Isa Ariyanti
6. Jurita Purnama Sari
7. Anggraeni Citra S.
8. M.Taufik Bachtiar
9. Alfat Ayu Marga
10. Shofi Khaqul Ilmy
11. Resti Lovita Nur
12. Arphido Prastyatama
13. Lailatul Purwasih Putri
14. Shindy Anggreini Putri
15. Arum Desi Pratiwi

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NURSING K3LN DEPARTMENT

MEDICAL FACULTY OF BRAWIJAYA UNIVERSITY
MALANG

2011
TRIGGER FOR PROBLEM SOLVING
CASE 1 :
Trigger LEN FOR STANDARD PRACTICE
As a student nurse, you observe a fellow nursing student making a medication error.
She is a good friend of yours and is visibly upset by her error. She is also afraid that
if she tells the clinical instructor, she could get a poor grade for clinical, and she
needs to have a good average to keep her scholarship. The client was not actually
harmed by the med error, and your friend seems sufficiently upset by the incident to
convince you that she wouldnt make a similar error again. What would you do?
Keywords:
1) Nurse student
Nurse student is Individuals enrolled in a school of nursing or a formal
educational program leading to a degree in nursing. Nursing students face a
large number of ethical issues, both in their capacity as students and
throughout their clinical training. Some issues are specific to nursing, and
others are the kinds of issues all students face. Nursing students need to
understand these issues, and to know where they can turn for assistance in
making these difficult decisions.
a) Educational Ethics
Many students, both nursing and non-nursing, have ethical concerns such as
cheating or plagiarism. It can be tempting to use an old paper from a former
student or to take the answers to a test that is being offered by another class,
for example. These kinds of ethical issues can plague a nursing student from
the beginning of the educational process until graduation.
Informed Consent :

In the nursing field and clinical, nurses must secure an

informed consent before a procedure is done on the
patient. This is true for simple procedures such as IV

installation as well as for surgical procedures. There is

always the risk that the nurse might not know enough
about the procedure to be qualified to obtain that
consent. In addition, a nurse might be afraid to ask for
consent when told to perform a procedure by the
medical professionals instructing the nurse.
Document Forgery : Forgery is a serious ethical issue. This involves not only
copying a signature, but also signing a document without
actually completing the process dictated in the paper.
For example, a nursing student might be asked to write
notes on a chart of a patient that he has not seen.
Writing the notes on a chart after the fact also can be
considered document forgery. This can cause difficulty in
treating the patient later on, and it can cause people to
believe the patient was seen at a time when he really
was not seen.
Crying Wolf :

Ethical issues can come up for nursing students dealing

with patients who "cry wolf," or complain of pain they
don't really have. This becomes an ethical issue for the
nurse as he struggles to decide whether to report these
pains to his clinical trainer or to ignore them as attentionseeking behaviors. He also needs to decide whether
these complaints are made for the purpose of seeking
drugs, and he needs to know how to identify drugseeking patients.

Finding Help :

It is important that nursing students remember that their

instructors and peers either have been or currently are
where they are. This allows the nursing student to
discuss the ethical issues and moral conflicts that she
might be experiencing. This can help the nurse develop
a strong ethical base, and it also might help other nurses
in similar situations.

Nursing students are responsible for learning the tenets and skills required of
nursing care, according to the National Student Nurses Association's Code of
Academic and Clinical Conduct, which aims to lay the student's ethical and
clinical foundation.
b) The Code
The code for nursing students calls on them to team up with faculty to
promote top quality care; avoid practicing skills for which they lack training;
abstain from mind-altering substances that impair judgment within an
academic or clinical setting; support access to student drug- and alcoholabuse rehabilitation programs; and uphold school policies that promote
academic and clinical excellence.
Learning Focus :

Nursing students must constantly strive to increase their

skills, according to the NSNA, which says that "a nursing
student's commitment to evidence-based practice and to
the health, well-being and safety of clients" is crucial
because "the client willingly gives the nursing student
their trust in her/his ability to provide nursing care in
accordance with their clinical education objectives."
Because health care is always evolving, nurses must
"continue to educate themselves formally and informally
throughout their careers to remain clinically competent to
meet the health care needs of increasingly diverse client
population across an ever-changing health care
environment," the organization states in its interpretative
statements about the code.
Professional development--through lifelong learning and
joining professional organizations for specialty nursing-is key to good nursing, according to the interpretive
statements.

c) Similarities to Professional Code

The

NSNA--a

50,000-member

nonprofit

for

students

in

associate,

baccalaureate, diploma and generic graduate nursing programs--established

the code to prepare student nurses for their careers, according to its website.
The code, like similar canons at nursing colleges, takes some of its material
from the American Nurses Association's Code of Ethics, which stresses
respect for the patients through deference to their autonomy and respect for
confidentiality.
d) Campus Advocate
Nurses must educate the community about public health concerns and threats
to personal safety; they should also support initiatives that oppose
homelessness, violence and other social ills, according to the professional
code.
Though relevant to nursing students who want to advocate for such causes
within their larger community off campus, this guideline particularly requires
nursing students to challenge college policies and environments that threaten
health care. Nursing students should defer to the school's grievance policy to
properly address the situation, the NSNA states.
e) Significance
Nursing students are expected to follow the professional nurses' code, in
addition to their own, because upholding these standards ensures
"accountability and optimal care for their patients," says the University of
Texas at Arlington's School of Nursing Code of Ethics. Such behavior enables
nursing students to maintain the public's trust and respect, according to the
university.

2) Clinical instructor
Nursing instructors teach patient care to nursing students in classroom
and clinical settings. They demonstrate care methods and monitor hands on
learning by their students. They instruct students in the principles and
applications of biological and psychological subjects related to nursing. Some
nursing instructors specialize in teaching specific areas of nursing such as
surgical or oncological nursing.
Nursing instructors may be full professors, assistant professors,
instructors, or lecturers, depending on their approximately 41,000 nursing
instructors employed in the United States.
The duties of clinical instrustor are develops and executes a teaching
curriculum for nursing students. A nursing instructor will explain specifics
about the job to the students so they are prepared to work with patients in
clinical settings. According to career planner, a nursing instructor lectures
students, conducts and supervises laboratory work, issues assignments, and
directs seminars and panels. As a nursing clinical instructor, it's important to
be patient and supportive of the students while pushing them to learn as much
as they can while in the classroom so they can perform well in the clinical
setting.
In a clinical learning environment, instructors work with students and
faculty to ensure the continued education of aspiring nurses, health
practitioners and service providers. This position requires instructors to have a
love of the profession for which they provide instruction along with an
appreciation of academics.
In addition, clinical instructors conduct nursing interventions and
observe medical, surgical and allied health treatments to facilitate workplace
learning while preparing, administering and grading examinations to
determine student performance and achievement.

3) Medical error
Any incorrect or wrongful administration of a medication, such as a
mistake in dosage or route of administration, failure to prescribe or administer
the correct drug or formulation for a particular disease or condition, use of
outdated drugs, failure to observe the correct time for administration of the
drug, or lack of awareness of adverse effects of certain drug combinations.
There are many possible causes of medical error:
a)
b)
c)
d)
e)
f)
g)

Communication errors
The increasing specialization and fragmentation of health care
Human errors resulting from overwork and burnout
Manufacturing errors
Equipment failure
Diagnostic errors
Poorly designed buildings and facilities

Instead of that, there are many possible types of medication errors:

a)
b)
c)
d)

Incomplete patient information

Unavailable drug information
Miscommunication of drug orders
Lack of appropriate labeling as a drug is prepared and repackaged into

smaller units
e) Environmental factors, such as lighting, heat, noise, and interruptions.

To protect the client from medication errors, nurses have traditionally

used as a guideline the five rights of drugs administration :

a. Right Drug
The nurse should:
1. Check the label when removing the drug container from the clients
medication drawer.
2. Check the drug when removing it from the container.
3. Check the drug before returning it to the clients medication drawer.
b. Right dose
The nurse must know how to reduce the risk of errorby correctly
calculating doses and having them double-checked before administration.

To prepare scored or crushed medications, the nurse should make sure

scored tablets are broken evenly. This practice will prevent overdosage or
underdosage of a medication.
c. Right client
The nurse should correctly identify the client by asking the client to state
his or her full name and checking the clients identification armband.
d. Right route
The nurse should consult the health care practitioner whenever a route is
not identified in the prescription, when the route indicated differs from the
recommended one, or when the nurse questions the choice of route
prescribed. For example, the nurse should not substitute an oral
medication for an intra-muscular medication simply because the oral
medication is available and the intramuscular one is not.
e. Right time
Nurses are responsible for knowing why a medication is ordered on
a certain schedule and for following that schedule as closely as possible.
To maintain the drugs effect, the nurse has to give the medication in a
timely manner.
Causes of medication error may also include difficulty in reading
handwritten orders, confusion about different drugs with similar names,
and lack of information about a patient's drug allergies or sensitivities.
When the nurse is in doubt, administration of a drug should be delayed
until specifically authorized by a physician.

4) Standard practice in nursing

A set of guidelines for providing high-quality nursing care and criteria
for evaluating care. Such guidelines help assure patients that they are
receiving high-quality care. The standards are important if a legal dispute
arises over the quality of care provided a patient.

Learning Objectives:

Students will be able to:

-

Identify the medication error

Explain the terms Nursing standard and patient safety

Discuss the nursing standard act based on INNA and ICN

As a nurse student, what would you do in relation to your friend have medical error?
On the other hand, nurse must implement base from standard practic.
Explanation the question base from framework of solving the standard practiceand
medical error follows:
1. Develop from baseline data
a. Nursing student 1 making a medication error
b. Nursing student 1 is a good friend of mine
c. Nursing student 1 hasnt told the clinical instructor yet related to the
medication error
d. Nursing student 1 needs to have a good average to keep her
scholarship
e. The client was not actually harmed by the med error
f. Nursing student 1 seems sufficiently upset by the incident
g. What should I do (as nursing student 2) to nursing student 1?
2. Identify the conflict because the situation

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Conceptual map is explained that

the student of nursing is the responsibility of the clinical instructor. While a student of
nursing which is responsible for a client have done of medication errors. Student
nursing two of my own to serving as a student of nursing 1 and then indirectly
involved in this. In accordance with the opening of the code of conduct by
management & nurse Indonesia, which is associated with the nurse and peer
relationships,

Nurses have always maintained good relations with other nurses and other
health workers, and maintain harmony in the workplace atmosphere and
achieve an overall health care (PPNI,2011)
Therefore, in the case as friends of my nursing students still have to be good friends.
To explain about what things should I do in terms of "good friends" I'll explain in the
"Problem Solving".
Based on these cases, it can be seen from various perspectives, both from the
viewpoint of WHO nursing students make medication errors, clinical instructor, and
we as a student nurse who was a friend of a nursing student and witnesses. In this
case one of the parties should not judge or justify a particular party because we are
required to think critically, logically and objectively.
a. Nursing student 1
Positive view :
Nursing student 1 seems sufficiently upset by the incident that
she was making the medication error. Its indicate that the
nursing student will not repeat mistakes. She still knows her
position and what mess she had done, so the dissappointment
feeling she had indicates her responsibility as nurse.
Negative view :
Nursing Student 1 was too scared and selfish to the client,
because just thinking about the future, as she could get bad
grades for clinical, and she needs to have a good average to
maintain the scholarship. Although medication errors that have
been made not to cause harmful effects for the client, but still,
her actions should be dealt with firmly. Assertive action by which
I mean in the form of punishment, but it depends on the decision

of clinical instructor in charge of the (nursing students) us.

In terms of knowledge-based practice that she has, nursing
student 1 may have got science in terms of intervention for a
client but, because of her status as still as a student, so she is
less able to decide was the right information and resources,
improve patient care and achievement of desired patient
outcomes. then she must learn more in future. responsibility &
accountability

for

nursing

practice:

and

competence by continual learning(ICN; 2006)

for

maintaining

In terms of standards of nursing practice conducted by student

1, it was clear that she is still not good and still have much to
learn. As said about Provision of Services to the Public, the
nurses provide nursing services in collaboration with the client,
significant others and other health professionals (International
Council of Nurses; 2006), so that he may think fit for the client's
decision after health professionals collaborate with others .

b. Clinical instructor
Positive view :

In this case, it didnt clearly explained about the actual role of

clinical instructor. Making it very difficult to identify the positive

side.
Negative view :
As the party responsible for student nurses, clinical instructor
lack of supervision to the nurse student. He/she must observe
their actions, primarily related to the provision of intervention for
the client.
3. Creating an alternative action on the planned course of action and consider
the outcomes or consequences of such action
In accordance with the opening of the code of conduct by Indonesian Nursing
Association, which is associated with the nurse and peer relationships, "Nurses
always maintain good relations with fellow nurses as well as with other health
personnel, and maintaining harmony in the workplace as well as in achieving the
objectives of service health "(INNA, 2011) Therefore, in the case as friends of the
nursing students I still have to be good friends.
So what should I do in terms of "being a good friend" is giving advice to a student of
nursing to inform about the medication errors that have been made to the client to
her clinical instructors. It is very important although the effect is not harmful to the
client, for students of nursing 1 does not make the same mistakes or worse mistakes

in the future. NURSE TAKES appropriate action tosafeguard individuals, families,

and communities when their health is endangered by a co-worker or any other
person (ICN;2006)
If a student notify the instructor of clinical nursing ,it is then likely that they exist:
Clinical Instructor gets angry - > reduce the grade of nursing students
clinical instructor is not angry - > forgive, and to offer solutions for the medication
errors that have been out of nursing students
4. Determine who the appropriate decision makers
Appropriate decision maker in accordance with this case is the nursing student who
has committed medication errors. Although it can affect the value or scholarships,
she still must take responsibility for his actions because it involves human life.
Nursing student 1 should informed to the clinical instructor about her medication
error.
As for clinical instructor, he/she was the one who has the authority to nurse student.
But

he/she

also

has

someone

in

higher

position

than

him/hers

(e.g.

professor,lecturer) who can punish or fire the clinical instructor as the result of his/her
lack of supervision to the nurse student.

5. Defining of duty nurse

Duty is an obligation created either by law or contract or by any voluntary action. It is
the first element that must be proved for malpractice as it arises from the nurse-client
relationship.

A nurse do their profession to fulfill the duties they have such as some points
below:

Perform all nursing duties in accordance with the state Nursing Act

Perform routine nursing care to assigned patients

Monitor patient progress and identifies any changes in status, acting on those
changes to insure patient comfort and safety

Actively demonstrate a working knowledge of nursing theory, techniques,

principles, and practice in order to holistically care for the patient

Must be able to perform various sensory requirements in order to assess and

treat the patient accurately.

Obedient to the nursing code of ethics.

Nurse must fullfill the standard practice in nursing whenever he/ she works

6. Making decisions
Based on data that have been identified above, now well make a decision
about what should we do related with this case. As on the mentioned info on the
case, the fault nurse is looked so upset and afraid. These kind of situation will make
we, as her friends on dilemmatic situation.
Here are the factors that causes dilemma :
1.
2.
3.
4.

The error medication is not harmfully effect through the patient

She is our good friend
It was her first time do medication error
She should keep her mark related with her scholarship
and cause of those factors, well explain the positive side (tell the instructor) and the
negative side (not tell the instructor).
From the first factor, The error medication is not harmfully effect through the
patient we may be think that it should not be reported since the error is not affecting
the patients because its not harmful. But, its completely wrong. As we can compare,
it look alike a thief who stole something. Once we let this thief steal, another day they
will be do the same. Same with this case, once we let she run from this case,
another day when she do the same thing, she will do the same. So that is why we
should tell the instructor about this. It is not about the effect that shown on patient,
but about the obedience to the rules.
The second factor She is our good friend . If we pretend that we did not
know anything bout what was happened, we are not a good friend for her. As a good
friend, we should make it as a good chance to affect her to complaining her fault.
And as a good friend, we should tell her which one is right and which one is wrong.
We should capable to give a persuasive explanation to her in order to make sure that
she can tell the instructor by herself and bravely tell her fault. If we do not tell the
instructor, we are a liar, cause we hide the truth, and its not suitable with the code of

ethic. It also called and immorality cause we are hiding the truth.
The third factor is It was her first time do medication error. Even it was her
first error, it does not matter cause once she done a fault. It still called a fault and it
is irreversible. Same like the first factor we cant let it go. It will be good if on her first
fault, she feel guilty and do wont to do it again someday. It can be a good motivation
for her. Because it will be a good experience for her to work carefully.
The last factor is She should keep her mark related with her scholarship.
She was worried bout her mark related with her scholarship. But its a selfish act that
done by her. She just pushed her rights and loose the patients right. Patients should
get a satisfaction during the medication. But what she did is not giving satisfaction
through the patients. As a professional nurse, those kind of act is should not be
done. If she tell the instructor, we never know what is exactly will happen. The
instructor may be give a positive mark or tolerate it cause she is still a student. So
the best way is just tell the instructor.

REFERENCES
American Nursing Association. SCOPE and STANDARDS of Nursing
Practice in Correctional Facilities. www.statepen.organa.htm.pdf accessed
on 14th april 2011 11.51 WIB
College and Association of Registered Nurses of Alberta. Nursing Practice
Standards. Canada : College and Association of Registered Nurses of
Alberta, 2005. www.nurses.ab.ca accessed on 14th April 2011 14.09 WIB
DeLaune, Sue C.and Ladner, Patricia K. Fundamental of Nursing; Standards
& Practice, Second Edition. United Stated of America : Delmar/ Thomson
Learning, 2002.
Hardy, CL. Clinical Instructor Job Description. www.eHow.com accessed on
13rd April 2011 17.35 WIB
Indonesian Nursing Association. Kode Etik Perawat Indonesia. www.innappni.or.id/ accessed on 17th April 2011 14.01WIB
International Council of Nurses. The ICN Code of Ethics for Nurses. Geneva:
International Council of Nurses,2006
Lestari, Fita. Standar Praktek Keperawatan Profesional di Indonesia
www.stikeskabmalang.wordpress.com accessed on 13th April 17.11 WIB
Medical Errors www.surgeryencyclopedia.com. Accessed on 13rd April
201118.01 WIB
U.S. Department of Health & Human Services. Medication Errors.
www.fda.gov accessed on 13rd April 201118.03 WIB
Uyeno, Joy. Job Description for a Nursing Clinical Instructor. www.eHow.com
accessed on 13rd April 201117.35 WIB