What are the Code of Conduct for nurses in India and analysis of cases

Introduction

The nurses are responsible for providing high-quality care to their clients/patients. In their clinical practice, nurses are without question faced with different ethical problems so they know about the ethical code of conduct and the basic aspects of ethical decision-making. In recent decades, codes of ethics have been adopted for many professions. Almost all recognized professional groups worldwide have also issued ethical codes of nursing, as one of the most trusted professions. The public is increasingly concerned about the ethical misconduct of medical professionals. This skepticism is also contributed by a growing public consciousness, technological advancements that make it difficult for the general public to access information, and an awareness of some practitioners in the field of ethics. Ethical misconduct in the field of healthcare may also indicate increased lawsuits and abuse against healthcare practitioners.

Medical ethics teaching is important to develop a health professional willing to analyze and solve different ethical dilemmas experienced in clinical and research activities. For healthcare professionals, excellence in clinical skills and a good knowledge of traditional bioethics standards and their implementation in clinical conditions are important. There are different standards for teaching and applying ethical principles in various medical areas, such as clinical practice and research. Globally, different professional bodies have emphasized the need to include ethical and legal considerations in the curriculum for medical education. Ethical practices in India primarily concentrate on four values sovereignty, charity, non-maliciousness, and justice. In the healthcare team, healthcare workers play an essential role in different fields, such as clinical treatment, research, and medical education. Ethical practices for good patient care are important for nurses.

Additional Read: Can unqualified staff be covered under medical indemnity insurance?

Cases against nurses in India

A.) Civil Surgeon cum chief superintendent & Anr. v. Varsha Chachlani (24^thSeptember 2020)

In the case, the complainant’s husband who was also the patient had chest pain in the morning at 8:25 am and was taken to the district hospital, Rajnanadgaon where the duty doctor examined him and instructed the staff nurse to take an immediate ECG, X-ray chest, blood and urine tests. It was argued by the complainant that he was willing to pay for all the tests, and despite that and after instructions from the doctor, the nurse did not bother to conduct the tests till 2 pm. The patient again suffered severe chest pain at 2 pm on which the nurse was again called and asked to conduct the tests but she refused to say that it is not possible for her to come to the same patient again and again. After thirty minutes when the students of the dental college came and called the nurse and physician, the physician declared the patient dead. Aggrieved by this, a complaint was filed before the district forum on grounds of medical negligence against the doctor as well as the staff nurse. The district forum allowed the complained and asked the opposite parties to pay compensation. When the matter went to the state commission, taken by the medical professionals, the appeal was dismissed. On this, the appeal was filed by them before the national commission.

The complainant reiterated the facts and argues that even the inquiry officer in his report mentioned the delay and thus it must be seen as a violation of the duty of care. The other side argued that the question of duty of care does not arise because the complainant was not a consumer since the service was free at this government hospital, and thus it is not “service” as defined under section 2(1)(o) of Consumer protection act 1986. Moreover, they argued that the complainant (the wife) was negligent as she did not submit the fee when tests were to be conducted. The court first deliberated that the argument made by the opposite side regarding non-payment shows that the services of conducting tests were not free for each and every patient, and some fee was charged. There is a possibility that some get free treatment in govt. hospital but this argument of the complainant herself being negligent shows that payment was taken from some patients. Also, it was observed by the court on the basis of an argument that free treatment was provided to patients with BPL cards, and the complainant was a BPL cardholder.

The commission on the basis of arguments of the doctor, nurse, and the report of the inquiry officer, held that the condition of the patient was critical when he was brought to the hospital and the tests were to be conducted immediately, which was not done due to the negligence on the part of the nurse and treating doctor. The commission also threw light on the aspect that, whether the service is free or not, it will fall within the ambit of section 2(1)(o) of the aforementioned act. It was observed that an elderly patient coming in with a complaint of chest pain is a serious matter and should have been dealt with accordingly, which did not happen in this case and thus the treating doctor and the nurse were held liable for negligence.

B.) The central Hospital v. Shri Jitendra Pandurang (10^thOctober 2017)

Jitendra filed a complaint on the ground that he is a police constable and thus he was entitled to get free of charge treatment at the central hospital, on grounds of being a govt. employee. However, he paid Rs 5 for registration, for which he was given a receipt. He was suffering from wrist pain for which an injection was administered according to the prescription issued by Dr. Vikas Dongare. The injection was administered by Nurse Surekha Sankhe. After the administration, his left arm went numb and he felt as if he got some electric current in his arm. He had complained to Nurse Surekha Sankhe about severe pain and abnormality noticed in his left arm. In consequence, the sudden critical condition developed with no signs of improvement. According to the complainant he was examined by Resident Medical Officer Dr. Bharati Patil, who had described physiotherapy treatment that he received at KEM Hospital without any fruitful result. According to him, opponents including hospitals were responsible for deficiency in service and medical negligence which resulted in injury to the complainant. While receiving medical treatment, he had to remain absent from his employment even without pay and was unable to discharge his duties efficiently and effectively as possible before the incident. As a result, the complainant suffered a lot. He had also lodged F.I.R. alleging criminal negligence and had called upon the opponents by legal notice dated to compensate him. The complainant prayed for compensation in the sum of Rs.15,71,687/- with interest @ 18% p.a. till actual payment is made.

Opponents had challenged the case on the basis that medical care was free and, as such, there was no cause for action against the complainant’s Government Hospital. The main objection of the award is that in the Government Hospital, medical care is provided free of charge to government workers and their families and, where service is free, the individual receiving free treatment is not a “consumer” under the scope of Section 2(1)(d) of the Consumer Protection Act, 1986.

The court observed that in cases on the basis of the principle of res-ipsa-loquitur, where the opponent treats the patient without proper care such as administering the injection, in the instant case by a nurse without bothering about consequences if the injection is wrongly administered, then such an irresponsible attitude or failure to take the duty of care, by a person concerned who administered the injection can surely primarily responsible for medical negligence on the ground that principle res-ipsa-loquitur due to administration of injection physical disability to the extent of 25 to 50% was caused as a result. In the instant case, according to the complainant, the registration fee was paid in the sum of Rs.5/- to the Government Hospital. In such cases, though as a Government employee or employee in the Police Department, he was entitled to receive medical treatment free of charge but under the supervision of competent doctors. It was not without any consideration. Be that as it may. The registration charge was accepted.

In such cases, when the patient suffered injury as a result of the wrong administration of an injection by a nurse without the supervision of a doctor not only principle of res-ipsa-loquitur is attracted but also once the complainant has discharged the initial onus of making out a prima-facie case of negligence against the Hospital or Nurse concerned, the onus is shifted upon the Hospital or the Nurse concerned to satisfy the  Forum that there was no lack of adequate care and caution. The forum also explained that government Hospitals are also liable for medical negligence and that patient in Government Hospitals is a “consumers”. Thus, any action amounting to an irresponsible attitude and failure in the duty to take care resulting in grievous injury to the patient enables him to complain on the ground that he is a consumer within the meaning of Section 2(1)(d) of the Consumer Protection Act, 1986 and can seek compensation particularly when there was a responsibility on the basis medical negligence caused to the patient in the Government Hospital. The nurse and the doctor were held liable for this negligence.

C.) Muljibhai Patel Urological Hospital v. Arunaben Desai (9 May 2008)

The respondent was appointed as a staff nurse and initially on probation for a period of six months. It is the case on behalf of the petitioner hospital that one Shri Abbas Ali was suffering from kidney diseases, was admitted as an indoor patient in the petitioner hospital, and was operated on for urine bypass surgery. The respondent nurse was on duty as a staff nurse on the night shift and was in charge of the said patient. Suddenly, at midnight the patient had started stomach pain and there was leakage of urine through the hole made in the abdomen which was closed. Therefore, the patient sent one Shri Bhikhabhai to call the nurse so as to call the concerned Doctor immediately. But she did not turn up. After some time again, she was called by the relatives of the patient but the respondent did not respond for an hour. After some time, the respondent responded and said that she cannot call the Doctor at this time and she will call in the morning. Thus, the respondent nurse did not attend to the patient.

The patient made a complaint to the Director of the petitioner hospital as the respondent nurse failed to discharge her duties honestly and diligently and committed serious misconduct of negligence. Looking at the gravity and seriousness of the misconduct, a departmental inquiry came to be initiated against the respondent nurse and she was served with a show-cause notice for her acts of subversion of discipline. After holding a legal and proper departmental inquiry; after giving the fullest opportunity to defend her case and after both parties led their evidence before the inquiry officer and after considering the evidence on record, the Inquiry Officer recorded his evidence and found the respondent nurse guilty of the charges leveled against her i.e. negligence and carelessness of duty as a nurse. The respondent nurse was served with a second show cause notice along with an inquiry report and she was called upon to show cause as to why her services should not be terminated looking at the gravity and seriousness of the proven misconduct and past record. At this stage it is required to be noted that in the last year, the respondent nurse was served with four notices for her negligence in her duties; two warnings for misbehavior with the superior officers; twice she was suspended for other misconduct, and once she tendered an apology. That after considering the explanation tendered by the respondent, the petitioner hospital management by order terminated the services of the respondent nurse.

Against the order of termination, the nurse raised an industrial dispute being referenced before the Labour Court, Nadiad claiming reinstatement with full back-wages. It was further contended that the respondent had committed grave and serious misconduct of negligence in discharging her duties as a staff nurse. It was contended that after a legal and proper inquiry into the charges leveled against the respondent, she was found to be guilty of the charges leveled against her, and with regard to the gravity and seriousness of the charges, her services have been terminated.

It is also required to be noted that before the Labour Court, the respondent nurse did not challenge the legality and validity of the inquiry, however, challenged only findings and quantum of punishment. The respondent did not lead any evidence against the findings of the Inquiry Officer before the Labour Court. On this matter, the forum relied on a supreme court decision and observed that in absence of a challenge to the legality or fairness of the inquiry report, the Courts should be reluctant to either interfere with the finding recorded by the punishing authority or the quantum. Since the respondent had not challenged the correctness, legality, and validity of the inquiry conducted, it was not open to the Labour Court to go into the findings recorded by the inquiry officer regarding the misconduct committed by the respondent. Considering this, it was observed that the Labour Court has committed an error in interfering with the findings recorded by the Inquiry Officer when the legality and validity of the inquiry were not challenged by the respondent nurse and more particularly when no evidence was laid by the respondent nurse before the Labour Court against the findings of the Inquiry Officer. Thus, the negligence of the nurse was upheld.

D.) Spring Meadows Hospital and another v Harjol Ahluwalia(25^th March 1998)

In this complaint of the minor child through his parents before the National Commission. it was contended that the child was admitted to the appellant hospital as an in-patient with a diagnosis of typhoid. The nurse asked the child’s father to purchase the injection Inj. Lariago was recommended by the Senor Paediatrician to be administered intravenously. When the nurse administered the injection, the child collapsed immediately. The resident doctor found that the child had. suffered cardiac arrest and he attempted to resuscitate the child by manual pumping. After half an hour, the Anaesthetist also reached the scene and started the procedure of manual respiration the Senior Paediatrician also followed but there was no improvement in the child’s condition.

On advice. the child was shifted to the All India Institute of Medical. sciences (AIIMS). The doctors at the AIIMS informed the parents that the child was in critical condition and that even if he survived, he would live only in a vegetative state has suffered irreparable damage to the brain. sometime later, the child was discharged and again admitted to the appellant hospital. Based on the evidence, the commission concluded that the child had suffered cardiac arrest because of intravenous injection of an excessive dose of the injection and that due to considerable delay in measures to revive the heart, the child’s brain had been damaged. The Commission found that there was a clear dereliction of duty on the part of the nurse and that the hospital was negligent in having employed an unqualified person as a nurse and entrusting the child to her care. It also held that the resident doctor was negligent since he failed to follow the instruction of the Senior Paediatrician that the injection. should be administered by a doctor. The Commission held that since the resident doctor and nurse were employees of the appellant hospital, the latter was liable and awarded compensation of Rs 12.51akh to the child and Rs.5 lakh to the parents for acute mental agony.

In the appeal of the hospital, the Supreme Court observed that because the Consumer Protection Act was beneficial legislation intended to confer. speedier remedy for consumers, its provisions should receive a liberal construction. The Court commented that the relation. hip between a doctor and the patient was not equally balanced as the patient’s attitude towards a doctor was poised between trust in the learning of another and the general distress of one in a state of uncertainty further observed that it was difficult for a patient to successfully bring a medical negligence case against the doctor given. the practical difficulties in linking the injury with the treatment and establishing the requisite standard of care. But it also noted that with the advent of the Consumer Protection Act, in a few cases patients had been able to establish the doctor’s negligence. The Court also indicated that the use of the wrong drug or gas during anesthesia or delegation of responsibility knowing that the delegated person was incapable of performing his duties properly were some instances of tortuous negligence.

The Court also rejected the contention of the hospital that the child’s parents were not covered within the definition of consumers in s. 2(1 )(d) of the Act and could not be awarded compensation separately. It held that when a child was taken to a hospital by his parents and the child was treated by a doctor, the parents would come within the definition of the consumer having hired the services of the hospital/doctor and the child would also be a consumer under the inclusive part of the definition, being a beneficiary of such services. Therefore, both the parents and the child would be ‘consumers’ and could claim and be awarded compensation.

Additional Read: Medical Establishment Insurance – All about Professional Indemnity Policy

Code of ethics for nurses

1. The nurse honors the individual’s special treatment – the nurse

• Provides treatment to people regardless of caste, creed, faith, culture, nationality, gender, socio-economic and political status, personal characteristics, or other grounds;
• Treatment is individualized to take account of beliefs, values, and cultural sensitivities
• Appreciates individuals’ roles in the family and society and enables significant others to participate in health care.
• Develops and facilitates trustworthy ties with people (s)
• Recognizes and adapts the individuality of human reaction to interventions

2. The nurse respects the rights of patients as a care partner and helps them to make informed decisions.

• Enjoys the right of individuals to take decisions about their treatment and provides appropriate and correct information so that they can make informed choices.
• Respects individual decisions about their treatment
• Protects the public from misinformation and misunderstanding
• Advocates for special measures to protect the vulnerable.

3. The nurse respects the right of the client to privacy, preserves confidentiality, and judiciously shares details.

• Respects the privacy rights of individuals to their personal data. 3.2 Maintains the protection of data security except in cases of life threats and exercises discretion when exchanging information.
• Taking informed consent and maintaining confidentiality where quality assurance/academic/legal reasons need details
• Limits access to all written and computerized personal records to approved persons only.

4. Caregiver retains integrity to provide quality care

• Treatment can only be given by licensed nurses
• Caregivers aim to ensure quality treatment and respect care standards
• Continuing education values Nurse values initiate and use all self-development resources.
• The nurses value research as a way of developing the nursing profession and engaging in ethically-compliant nursing research.

5. If the caregiver is required to practice within ethical, technical, and legal limits – the nurse

• Adheres to the Indian Nursing Council Ethics Code and to the Indian Code of Professional Conduct
• Familiarized with applicable State laws and practices

6. The nurse must function in harmony with the health team – nurse members

• Enjoy the team’s efforts in providing treatment
• Cooperate, organize and work with health team members to meet people’s needs

7. Nurse undertakes to reciprocate the confidence expended by society in the nursing profession Nurse

• Demonstrate personal labels in all transactions
• Proof of technical qualities in all transactions

Code of professional conduct for nurses

I. Professional liability and responsibility

• Appreciate and cultivate a sense of self-worth
• Maintains personal conduct expectations expressing credit about the occupation
• Exercises obligations in the context of the Professional limits
• Is responsible for upholding standards of practice of the Indian Nursing council
• Responsibility for own decisions and behavior
• Is compassionate
• Is responsible for the ongoing positive change of existing conditions practice
• Provides sufficient information to people to help them make informed choices
• Practices Healthful behavior

II. Practice in Nursing

• Provides treatment in line with established practices guidelines
• Treat all persons and families with human dignity by providing physical, psychological, mental, social, and spiritual aspects of treatment
• Respect for individuals and families, practices of tradition and culture that promote safe practices and deter unsafe activities
• Presents a realistic picture truthfully in all situations for facilitating autonomous decision-making by individuals and families
• Promotes involvement of individuals and others in the caring
• Ensures safe practices
• Consults, coordinates, collaborates, and follows up appropriately when individuals’ care needs exceed the nurse’s competence

 III. Communication and interpersonal relations

• Successful interpersonal relationship establishment and maintenance with individuals, families, and community
• Upholds the dignity of team members and maintains effective interpersonal relationships with them
• Appreciates and nurtures the professional role of team members
• Works with other health professionals to meet Person, family, and community needs

 IV. Valuing Human beings

• Takes reasonable measures to protect people from damaging and nonethical procedure
• Considers relevant facts while taking conscience decisions in the best interest of individuals
• Encourages and supports individuals to talk for themselves on health and welfare matters
• Respect and endorse individual decisions

V. Management

• Ensure proper distribution and use of the available resources
• Participates in student’s and other care providers’ supervision and curriculum and structured treatment
• Uses judgment in relation to individual competence while accepting and delegating responsibility
• Enables a leading culture of work in order to achieve institutional goals
• Communicates effectively following appropriate channels of communication
• Takes part in the performance assessment
• Participates in nursing care assessment
• Participates in policy decisions, following the principle of equity and accessibility of services
• Works with individuals to identify their needs and sensitizes policymakers and funding agencies for resource allocation

 VI. Nursing Professional Advancement

• Ensures human rights security when seeking the promotion of intelligence
• Contributes to the growth of nursing practices
• Participates in quality care determination and implementation
• Accounts for updating own knowledge and competency
• Contributes to the core of professional knowledge by conducting and participating in research

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