Learn — Legal & ethical aspects, professional regulation

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Indian Nursing Council — the INC Act 1947, registration and the state councils

The Indian Nursing Council is the statutory body created by the Indian Nursing Council Act of 1947 to establish a uniform standard of training for nurses, midwives and health visitors across India, to recognise the institutions that give it and to maintain the Indian Nurses Register. It regulates nursing education at the national level, while the registration and licensing of the individual nurse is the work of the State Nursing Councils under their own state Acts.

The Indian Nursing Council Act was passed by Parliament in 1947 and the Council was constituted in 1949 with its office in New Delhi; it has a President and Vice-President and members drawn from every state council, the universities, the medical council, the Directorate General of Health Services and nominees of the central government.
Its functions are to prescribe the syllabus and the minimum standards for every nursing programme — ANM, GNM, BSc, post-basic BSc, MSc and doctoral — to inspect and recognise the institutions that run them and to withdraw recognition when they fall short, to recognise qualifications from India and abroad, to maintain the Indian Nurses Register, to lay down the code of ethics and professional conduct and to promote continuing nursing education.
The Council does not register individual nurses: the State Nursing Registration Council of each state, under the state's Nurses Registration Act, registers nurses, midwives and ANMs after training, issues the registration certificate, renews it at intervals, keeps the state register and can remove a name for professional misconduct; the first such Act was the Madras Nurses and Midwives Act of 1926.
Registration is what makes practice lawful, a nurse who moves to another state registers there by reciprocal registration on the strength of her home registration, and the Council's Nurses Registration and Tracking System gives every registered nurse a single national identifier across the state registers.
The professional bodies sit beside the regulators: the Trained Nurses' Association of India, founded in 1908 and India's member of the International Council of Nurses since 1912, runs the Student Nurses' Association and publishes the Nursing Journal of India; the International Council of Nurses, founded in 1899 with its office in Geneva, writes the international code of ethics; and the Nursing Research Society of India promotes research.
The National Nursing and Midwifery Commission Act of 2023 provides for a National Nursing and Midwifery Commission to take over the Council's work under a new framework; until the provisions are brought into force by notification, the 1947 Act and the Council continue to govern, and a question that asks for the year of the Act that created the Council is answered 1947.

Legal aspects — negligence, malpractice, assault, battery and torts

The legal aspects of nursing are the parts of the law that define what a nurse may do, what she must do and what she answers for when a patient is harmed; they come from statute, from the regulations of the nursing councils and from the common law of torts and contracts as the courts apply it. The examinable core is the vocabulary of civil and criminal wrong — negligence, malpractice, assault, battery, false imprisonment, defamation — and the standard of care against which a nurse is judged.

A tort is a civil wrong for which the remedy is compensation; the unintentional torts are negligence — the failure to give the care a reasonably prudent nurse would have given in the same circumstances, proved by four elements: a duty owed, a breach of that duty, damage, and causation between the breach and the damage — and malpractice, which is negligence by a professional acting in her professional capacity.
The intentional torts each have one defining feature: assault is a threat or attempt that puts the patient in fear of harmful contact and needs no touching ('if you do not take it I will hold you down'); battery is touching without consent, such as giving an injection to a patient who refused it; false imprisonment is unlawful restraint or detention; invasion of privacy is exposure or disclosure without consent; and defamation is a false statement that damages reputation — libel when written, slander when spoken.
The same act may also be a crime: causing death by a rash or negligent act is punishable under the penal code, and a nurse can be prosecuted for it and sued for compensation as well; under the Consumer Protection Act of 2019 a patient who paid for treatment is a consumer, the health service is a service, and a claim for a deficiency in it goes to the district, state or national consumer commission.
The standard of care is that of the reasonably prudent nurse with the same qualification in the same situation, shown through the hospital's policies and procedures, the Council's syllabus and code, textbooks and expert evidence; res ipsa loquitur — the thing speaks for itself — applies where a swab is left inside a patient, and respondeat superior makes the employer vicariously liable for the nurse's act in the course of employment without freeing the nurse herself.
The common nursing negligences are the medication error, the fall, the failure to monitor and to report deterioration, the burn from a hot-water bottle, the wrong patient, the lost belonging and abandonment of a patient in one's care, and the nurse's defence in every one is the record — care not recorded was not given.
A nurse who carries out an order she knows to be wrong is liable together with the prescriber, so an unclear or unsafe order is questioned, clarified, refused if need be and escalated in writing; a verbal or telephone order is read back and countersigned by the prescriber; and the good-samaritan protection in the Motor Vehicles Act of 2019 shields a nurse who helps an accident victim on the road in good faith.

Consent and patient rights — informed consent, minors, emergencies, confidentiality

Consent is a patient's voluntary agreement to a proposed examination, treatment or procedure, given with the capacity to decide and after enough information to make the decision his own; treatment without it is battery however skilled the hands. Patient rights are the wider set of entitlements — to information, privacy, confidentiality, a second opinion, refusal and redress — that the Charter of Patients' Rights drawn up by the National Human Rights Commission lists, and consent is their sharpest expression.

A valid consent needs capacity — an adult of 18 years or more of sound mind, the age of majority under the Indian Majority Act — voluntariness, with no coercion or undue influence and never obtained from a sedated or frightened patient, and information: the nature and purpose of the procedure, its benefits and material risks, the alternatives and the consequence of refusing, given in a language the patient understands; it is specific to the procedure, and it is obtained by the person who will perform it, while the nurse witnesses the signature and confirms the patient understood.
Consent is implied when a patient holds out his arm for an injection, expressed when spoken or written, and written consent is required for surgery, anaesthesia, invasive procedures, blood transfusion, HIV testing, sterilisation, termination of pregnancy and research; the general consent signed at admission covers routine care only, and sterilisation and termination need the consent of the person herself, not of the spouse.
For a minor under 18 the parent or legal guardian consents and the child's own assent is sought and recorded; for an adult who lacks capacity a legally authorised representative decides, and the Mental Healthcare Act of 2017 lets a person appoint a nominated representative and write an advance directive while well.
In an emergency, when the patient cannot consent and no proxy is at hand, life-saving treatment proceeds under the doctrine of necessity; a competent adult's refusal, however, stands even when it will cost his life, a refusal is recorded in his own words and reported, and a patient leaving against medical advice signs a statement to that effect after the risks are explained.
Confidentiality is a right with named exceptions — information is shared with the team for care, disclosed when the law requires (a notifiable disease, a court order, a medico-legal case) and when it will prevent serious harm to an identifiable person — and the HIV and AIDS (Prevention and Control) Act of 2017 makes informed consent for testing and confidentiality of status statutory duties.
The Charter of Patients' Rights adopted for the country in 2018 and 2019 lists, among others, the rights to information and to records, to emergency care, to informed consent, to confidentiality and privacy, to a second opinion, to transparency in rates, to non-discrimination, to safe and quality care, to choose the source of medicines, to proper referral and transfer, to protection in research, to discharge and to grievance redress — and the nurse is the patient's advocate for every one of them.

Ethics in nursing practice — autonomy, beneficence, veracity, fidelity and dilemmas

Ethics in nursing practice is the disciplined reasoning about what a nurse ought to do when the right course is not obvious, using the principles the profession has agreed on and the codes the ICN and the INC have written from them. It differs from law in that it binds even where no statute reaches, and a real ethical dilemma is a conflict between two defensible principles — most often autonomy against beneficence — which is why the answer is a structured process rather than a reflex.

The principles have exact names: autonomy is the competent person's right to decide, expressed as informed consent and refusal; beneficence is acting for the patient's good; non-maleficence is doing no harm; justice is fairness in treatment and in sharing scarce resources; veracity is truthfulness; fidelity is keeping promises and being faithful to the patient; confidentiality is guarding what one learns; and accountability is answering for one's own judgement and acts.
The theories behind them: deontology (Kant) judges an act by the rule or duty it follows whatever the outcome, teleology or utilitarianism (Bentham, Mill) judges it by its consequences — the greatest good for the greatest number — virtue ethics looks at the character of the nurse, principlism (Beauchamp and Childress) applies the four principles, and paternalism is overriding a competent patient's choice for his own good.
The ICN Code of Ethics, first adopted in 1953 and revised in 2021, is arranged under four elements — nurses and patients or other people requiring care, nurses and practice, nurses and the profession, and nurses and global health; the Indian Nursing Council's Code of Ethics and Code of Professional Conduct make the nurse accountable for her own judgement, bind her to confidentiality and to the patient's rights and customs, and require her to keep her competence current; the Nightingale Pledge of 1893 is the profession's older oath.
Ethical decision making follows steps — gather the facts, identify the people and values involved, name the principles in conflict, list the options and their consequences, decide, act and evaluate — and the hospital ethics committee exists for the cases one nurse should not decide alone; the MORAL model (massage the dilemma, outline the options, review and resolve, act, look back) is one such sequence.
The recurring dilemmas are truth-telling when the family asks that a diagnosis be hidden, refusal of life-saving treatment by a competent adult, end-of-life decisions — passive withdrawal of life support under an advance directive is lawful since the Common Cause judgment of 2018, active euthanasia is not — allocation of a scarce bed or ventilator, confidentiality against the duty to warn an endangered partner, and reporting an unsafe colleague.
Moral distress is knowing the right action and being prevented from taking it; a dilemma is not knowing which of two right actions to take; and the nurse's role in both is advocacy — questioning, escalating in writing and recording — rather than silent compliance.

Laws affecting nursing — MHCA 2017, CPA 2019, MTP and PCPNDT Acts

Beyond the councils' own Acts, a nurse works under a set of general laws that fix what she may do for a patient, what a patient may demand of her and how a hospital must run; the examinable ones are known by their year, and the stems describe a situation and ask which Act governs it. They cover mental health, consumer redress, termination of pregnancy, sex selection, organ transplantation, drugs, the workplace and the newer rules on clinical establishments and data.

The Mental Healthcare Act of 2017, which replaced the Act of 1987, gives a person with mental illness the right to write an advance directive while well — how he wishes and does not wish to be treated — and to appoint a nominated representative, provides for independent (voluntary) and supported admission reviewed by Mental Health Review Boards, decriminalises attempted suicide by presuming severe stress, and bans electroconvulsive therapy without anaesthesia and on minors as well as chaining and solitary confinement.
The Consumer Protection Act of 2019, which replaced the Act of 1986, treats a patient who pays for treatment as a consumer and health care as a service, so a claim of negligence or deficiency goes to the district, state or national consumer commission for compensation, with mediation available at each level.
The Medical Termination of Pregnancy Act of 1971, as amended in 2021, allows termination up to 20 weeks on the opinion of one doctor, from 20 to 24 weeks for specified categories such as survivors of rape or incest, minors and women with a foetal anomaly on the opinion of two, and beyond 24 weeks for a substantial foetal anomaly on the decision of a Medical Board; the consent is the woman's own — a guardian's only for a minor or a woman with mental illness — and her identity is confidential.
The Pre-Conception and Pre-Natal Diagnostic Techniques Act of 1994, amended in 2003, prohibits sex selection and the disclosure of the sex of the foetus by any means, registers every ultrasound machine and clinic and punishes the person who asks as well as the person who tells; the Transplantation of Human Organs and Tissues Act of 1994, amended in 2011, defines brain-stem death, limits living donation to near relatives unless an authorisation committee approves and outlaws commerce in organs.
Under the Drugs and Cosmetics Act of 1940 and its Rules of 1945, Schedule H drugs are sold on prescription only, Schedule H1 covers habit-forming drugs and the higher antibiotics for which the chemist keeps a register, Schedule X covers narcotic and psychotropic drugs that need a duplicate prescription and retained records, and Schedule G drugs carry a caution; the Narcotic Drugs and Psychotropic Substances Act of 1985 is why the ward's narcotics live in a double-locked cupboard with a register.
The rest are asked by their one fact: the Registration of Births and Deaths Act of 1969 requires reporting within 21 days; the Maternity Benefit Act of 1961 as amended in 2017 gives 26 weeks of paid leave; the Sexual Harassment of Women at Workplace Act of 2013 requires an internal committee in every hospital; the Clinical Establishments Act of 2010 registers hospitals and sets minimum standards; the Protection of Children from Sexual Offences Act of 2012 makes reporting mandatory; the Epidemic Diseases Act of 1897, amended in 2020, punishes violence against health workers; and the HIV and AIDS Act of 2017 protects consent and confidentiality.

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