Concomitant with the development of a theoretical base, the role of nurses has undergone a paradigm shift, leading to the expansion and extension of their clinical roles in a number of specialized areas. Commercialization of the medical profession has resulted in large scale mushrooming of hospitals, nursing homes and clinics on one hand and the patients developing an attitude of “shopping” with his/her disease on the other. Nursing colleges and institutes have grown in manifold ways, to exploit this lucrative business. The number of Auxiliary Nurse Midwife (ANM) colleges has grown from 271 in Mar 2006 to 1113, while the number of General Nursing and Midwifery (GNM) colleges has increased from 1321 to 1961 by August 2013 [1,2].
The nurses in India are generally basking under the impression that the onus of all omissions and commissions rests with the doctor and the hospital administration, and that they are not accountable for anything. The enactment of various legal provisions like Consumer Protection Act, India, 1986 (CPA), Right to Information Act, 2005 (RTI) and standardization of procedures and practices has brought nursing care under the legal ambit and focus, more than ever before. Needless to say, the level of legal awareness amidst nursing staff in India is abysmally low. Even in developed countries like USA, the number of adverse actions reported to NPDB, related to nurses in 2011, was nearly double of that which was seen in 2002 (21,586 vs. 11,029 respectively) [3].
However, of late, nurses in India have been in the limelight for negligence and cases of criminal medical negligence against nurses are also being registered in courts [4]. The growing awareness on literate and net savvy consumers, the prying eyes of the media and the race for breaking news will ensure that such cases will be hard to put under the carpet in the future. It is time for nurses to understand that doctors will no longer be party to negligent acts attributable to nursing care.
With this in the backdrop, the present study was undertaken to assess legal awareness and knowledge on basic nursing procedures among the nursing staff in a trust hospital.This study was also prompted by the fact that very few similar studies had been undertaken in our country.
Material and Methods
The present study was carried out at the Healthcare Management Institute (HMI), KEM Hospital, Pune, in 2010 – 2011. On the date of commencement of study, the total nursing staff posted at the hospital were 510. Among these, the ANM and GNM qualified staff were 443 (ANM - 139, GNM - 304), while remaining nurses were trained in various specialities. This being a pilot study, only 20% of the ANM and GNM qualified nurses deployed at the nursing home and general wards were randomly selected, while the trained nurses were excluded. Keeping in view the ethical consideratons, the participants were explained the purpose and the methodology of the study and their consents were obtained.
A cross–sectional, randomized study was designed to assess the level of legal awareness and knowledge on basic nursing procedures carried out, among the nursing staff. The topic for the study was approved by the director, HMI. The study was undertaken after getting due permission from the Medical Administrator of the hospital.
An open ended questionnaire was prepared and it was validated after discussion with the peer group, director of the institute and the matron of the hospital. The questionnaire comprised of 25 questions. The questions were a mix of multiple choice and single line answers. Questions were broadly divided to judge the following aspects:
First nine questions were asked to evaluate basic legal knowledge and awareness. The results were analyzed using three parameters viz - qualification, age and experience.
Three questions were asked to ascertain as to whether any training on legal aspects was imparted to them at any stage of their careers.
Twelve questions were asked to evaluate knowledge on established basic nursing procedures. The results were analyzed using same parameters viz - qualification, age and experience.
The nurses under study were asked only one question, to find out whether they were aware about any legal complaints made against nurses and any action which was taken against them.
An Interaction, based on verbal discussions, after submission of questionnaire was conducted, to ascertain as to how legal knowledge would be helpful in their profession and whether the interaction was useful to them.
Results
The results provided interesting statistics and they reflected the state of legal awareness and flaws in routine nursing procedures.
Nine questions were asked to evaluate the factual basic legal knowledge and awareness. The results were analyzed separately, based on qualification, age and experience and they were summarized as under [Table/Fig-1].
Legal knowledge based on nursing qualification, experience and age
| a. Based on qualification |
|---|
| Qualification | Average Score in % | Range of Marks |
| GNM | 24.85 | 08.82 - 44.12 |
| ANM | 19.7 | 05.88 - 41.18 |
| b. Based on experience |
| Experience in Years | Average Score in % | Range of Marks |
| 0 - 2 | 22.74 | 05.88 - 44.12 |
| 2 - 10 | 15.68 | 05.88 - 26.47 |
| > 10 | 28.75 | 11.76 - 41.18 |
| c. Based on age group |
| Age Group | Average Score in % | Range of Marks |
| 21 - 30 | 21.05 | 05.88 - 44.12 |
| 31 - 40 | 25.49 | 08.82 - 32.35 |
| > 40 | 28.24 | 11.76 - 41.18 |
The analysis of results, based on qualification, revealed that knowledge on various legal provisions thereof, as was applicable to nursing, across all categories of nurses under review, was found to be poor. However, the nursing staff with GNM qualification fared better than those with ANM qualification, as has been depicted in [Table/Fig-2].
Legal knowledge based on nursing qualification
The analysis of results based on the experience of nursing staff, revealed that the knowledge of nursing staff on various legal provisions was highest among those with more than 10 yrs of experience and that they obtained highest average score of 28.75 % [Table/Fig-3].
Legal knowledge based on experience
The analysis of results based on ages of nursing staff revealed that the knowledge of nursing staff on various legal provisions consistently improved with age, as has been shown in [Table/Fig-4].
Legal knowledge based on age
Three questions were asked to ascertain as to whether any training on legal aspects was imparted to them at any stage of their career. A majority of the respondents categorically denied having received any structured or unstructured training during their basic training or subsequently, through their employers. Lack of time, ignorance and lack of IT skills were main reasons for not keeping themselves abreast with legal updates.
Twelve questions were asked to evaluate their basic knowledge on established nursing care and procedures. The results were analyzed separately, based on qualification, age and experience and these have been summarized in [Table/Fig-5].
Knowledge of established basic nursing procedures according to qualification, experience and age group
| a. Based on qualification |
|---|
| Qualification | Average Score in % | Range of Marks |
| GNM | 54.86 | 30.56 - 72.22 |
| ANM | 48.05 | 22.22 - 80.56 |
| b. Based on experience |
| Experience in Years | Average Score in % | Range of Marks |
| 0 - 2 | 56.11 | 30.56 - 72.22 |
| 2 - 10 | 35.64 | 22.22 - 47.22 |
| > 10 | 58.02 | 36.11 - 80.56 |
| c. Based on age group |
| Age Group | Average Score in % | Range of Marks |
| 21 - 30 | 51.09 | 27.78 - 72.22 |
| 31 - 40 | 49.07 | 22.22 - 69.44 |
| > 40 | 59.44 | 36.11 - 80.56 |
The analysis of results based on qualification, revealed that knowledge of various established basic nursing procedures, across all categories of nurses under review, was found to be satisfactory. However, the nursing staff with GNM qualification fared slightly better than those with ANM qualification [Table/Fig-6].
Knowledge of nursing care and procedures based on Qualification
The analysis of results based on the experience of nursing staff, revealed that the knowledge of nursing staff on various established basic nursing procedures was highest among those with more than 10 years of experience [Table/Fig-7].
Knowledge of nursing care and procedures based on experience
The analysis of results based on age of nursing staff, revealed that the knowledge of nursing staff on various established basic nursing procedures was highest among those who were more than 40 years of age [Table/Fig-8].
Knowledge of nursing care and procedures based on age
The nurses under study were asked only one question to find out whether they were aware about any legal complaints made against nurses, which was related to their professional negligence. A total of 47% nurses admitted to having some knowledge on such cases of negligence caused by nurses, which were mainly related to wrong administration of injections and drugs to patients [Table/Fig-9]. However; the punishments awarded were very lenient and they ranged from simple written warnings to a change of department. Only in exceptional cases, the nurses were removed from service. However, no cases were referred to the ‘State Nursing Council’ for action.
Awareness about complaints in hospitals and their disposal
Discussion
Nurses are one of the largest groups of professionals working in the health care system and they play a very important role, which helps in the speedy recovery of patients. In India, so far, they have remained insulated from being made a party in legal suits, primarily due to in house settlement of complaints by the hospitals and ignorance on the part of the patients. Those working in government or government aided hospitals have been provided with reasonable immunity. However, this situation is not going to remain same for long, as various legislations enacted by the government, notably The Consumer Protection Act and the Right to Information Act, are already in place. Hence, reliance is being placed on malpractice/negligence suits in USA and on cases that have been documented in India [5,6].
The present study revealed that the knowledge on laws and various legal provisions thereof, as was applicable to nursing, across all categories of nurses under review, was inadequate, to say the least. Both ANM and GNM nurses need a well-conceived education program on specific areas of legal aspects, such as legal terms, basic rights, legal control, taking physicians’ orders on telephone, legal obligations and patients’ rights. The nursing staff were also not fully aware about patient’s rights and legal obligations of nurses towards them.
The results of the present study were also consistent with the findings of similar studies done in India and abroad, which also indicated huge deficits in their knowledge, both on legal as well as ethical issues i.e. Kumar et al., [6] in their study in Jaipur, Rajasthan, reported that a majority (90%) of the nurses possessed only a moderate level of knowledge on legal awareness. Hariharan et al., [7], in their study on ‘Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados’, found that only 20% of senior nursing staff knew little on the law which was pertinent to their work. In another study done by Sharmil [8] in Malaysia on ‘Awareness of community health nurses on legal aspects of health care’, it was observed that only 11.7% nurses had the expected adequate level of knowledge on legal aspects of health care, while the remaining 88.3% nurses had only a moderate level of knowledge.
Our study further revealed that the main source of knowledge of the nurses on healthcare ethics was their training; and the same should be used to reinforce ethical knowledge and practice. Similar views have been advocated by Hanson and Dash. This was in accordance with the study done by Hanson in 2005 and Dash in 2010 [9,10].
There are not too many cases of legal suits filed against nurses in India, as our patients and their relatives still feel that the responsibility of any criminal negligence in patient care lies with the doctors. However, there have been criminal suites of medical negligence against nurses and the notable ones among these are:
Unskilled treatment of a high risk pregnancy at Jeevan Hospital at Tanjore Road near Tiruchirapallli in Tamil Nadu (1994), resulting in death of the foetus [11].
Partial disability of leg, caused due to administration of injection by an unqualified nurse in 1995 at Karuna Hospital in Thiruvanthapuram [12].
Permanent brain damage caused by negligence of nurse in administration of drug at Spring Meadows Hospital in 1993 [13].
Death of an Infant caused by negligence of nurse on duty on 22 February 2010 at Government Medical College, Nagpur [14].
A very recent case of a mismatched blood transfusion carried out by a nurse in Bangalore at KC General Hospital, resulting in death of patient [15].
All nurses should be familiar with nursing laws and ethics and they should understand as to how nursing legal issues can affect them. Basic nursing laws which all nurses should know are:-
Signatures are Golden: When a physician or another health care provider orders that a procedure be done on a patient, it is the nurse’s responsibility to obtain the patient’s informed consent and signature. If the nurse does not obtain his/her signature, both the nurse and the health care provider can be held liable for damages.
Documentation: It is the nurse’s responsibility to make sure that everything that is done with regards to a patient’s care (vital signs, specimen collections, medication administration, etc.) is documented in his/her chart/case sheet. If they are not documented within the proper time frame, the nurse can be held liable for negative outcomes. A note of caution: if an error is made on the chart, it should be crossed out with one line (so that it remains legible) and the correction and the cause of the error should be noted.
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 (emotional, sexual, physical, and mental) towards a vulnerable population (children, elderly, or domestic). If no report is made, the nurse has to be heldliable for negligence or wrongdoing towards the victimized patient.
Rights to Privacy: The nurse is responsible for keeping all patient records and personal information private and only accessible to the immediate care providers. If records get out or a patient’s privacy is breached, the liability lies on the nurse, because the nurse has immediate access to the records.
Conclusion
The analysis of the results has brought to fore, a large number of issues that need to be addressed in view of the rapidly changing canvas of modern nursing in India. The increasing role of a nurse as a patient care taker and advocate, on one hand and her requirement of having in depth knowledge of the legality of her actions on the other hand, have raised the bar of nursing. The changes in the health status of a patient can be gradual or sudden and nurses are usually the first to see the changes and to take action. A nurse’s accuracy in assessing, monitoring and reporting of changes in health status in time, to a physician, can often spell the difference between life and death.
Having seen the level of legal awareness among nursing staff, it would be reasonably safe to conclude that the knowledge of legal responsibilities is integral to the expanding clinical role, and a logical application of the planned, systematic, and focused care, should be the goal of modern nursing. The present study has substantiated the fact, that nurses need to know the laws that govern their profession, and that in the times to come, it will be increasingly difficult to avoid filing lawsuits against them.