NURSING ETHICS

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.

Abstract

The American Nurses Association (ANA) Code of Ethics for Nurses contains nine provisions developed for nurses to guide them in everyday nursing practice, helping nurses carry out their responsibilities and the ethical obligations when caring for patients. Making ethical decisions is an essential part of nursing practice. It involves specific values, attitudes, and conduct that nursing as a profession carry forward to benefit patients, the profession of nursing, and society as a whole. Nursing ethics according to the ANA and case examples of each ANA provision are discussed.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 1 Continuing Nursing Education Course Planners William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster, Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2.5 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Ethical decision-making is a necessary part of nursing practice. The professional practice of nursing is always changing and evolving to address the complex needs of society and of healthcare. Nurses need to be educated on ethical decision-making in healthcare to stay abreast of issues and to be actively involved as professionals in the dialogue of ethics.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 2 Course Purpose

To provide nursing professionals with knowledge of the American Nursing Association’s (ANA) code of ethics and practical applications of the code in clinical situations.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 9/19/2018

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 3 1. Ethics are defined as a. behaviors/attitudes that a group considers desirable or harmful. b. personal feelings about right and wrong. c. beliefs that categorize attitudes and behaviors as good or bad. d. a system of morality.

2. Which of the following is a specific provision of the ANA code of ethics? a. Nurses should not profit unreasonably from their work. b. The nurse’s primary commitment is to the patient. c. A nurse should collaborate with other healthcare professionals. d. Nurses not interfere with a patient’s decision to refuse treatments.

3. True or false: The ANA code of ethics is considered equivalent to laws. a. True. b. False.

4. The ANA code of ethics states that nurses have responsibility for nursing practice. a. This provision is used to assign legal responsibility for nursing actions. b. This provision is intended to differentiate nurses from physicians. c. This provision reinforces that nurses are independent professionals. d. This provision clearly outlines what nurses can and cannot do.

5. Ethical decisions a. frequently require collaboration with other healthcare professionals. b. are seldom complicated or difficult. c. seldom require collaboration with other healthcare professionals. d. should never involve the patient; the nurse is the professional.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 4 Introduction

The relationship between a nurse and patient is one of trust, responsibility, and caring. The healthcare environment is a professional workplace where nurses interact not only with patients but also with their co-workers and others. Because of this, the profession of nursing is inextricably linked with ethics. Ethics, in its simplest terms, means doing what is right.

Doing what is right is part of the daily functions of the nurse. While ethics is part of every profession, each one has its specific ethical concerns. This module will examine ethics that are specific to nursing.

Ethics, Values, And Morals

This module will discuss the ANA’s code of ethics and the nine provisions of that code. In order to provide a background for that discussion, ethics, morals, and values will be defined and explained.

Ethics

Ethics involves specific behaviors and attitudes that a group of people or a society considers to be beneficial and desirable, as well as attitudes and behaviors that are considered bad and harmful. Ethics could also be considered as principles of conduct. Additionally, ethics are social in nature.

Some of the aspects of ethics in healthcare are listed in Table 1, which relate to privacy, confidentially, beneficence, nonmaleficence, human dignity, informed consent, and autonomy.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 5 Table 1: Ethics In Healthcare

Privacy - Seclusion from the presence of others Confidentially - Spoken, written or acted on in privacy Beneficence - Doing good, performing acts of kindness Nonmaleficence - Doing no harm Human Dignity - Respect for the intrinsic worth of humans Informed Consent - Right and responsibility to freely and voluntarily consent or refuse treatment or a procedure, and being given enough information to do so. Autonomy - Ability of an individual to maintain control over her/his life and health.

Values

Values are beliefs about attitudes and behaviors, and values categorize attitudes and behaviors as good or bad. Although we can offer explanations and rationales for our values, a value cannot truly be explained or defended; it can only be believed in or not, adhered to or ignored. Despite that, there are many values that are shared by essentially everyone and almost universally accepted to be good or bad.

Morals

Morals are closely connected to values, but the term moral is used to describe a person’s values. Someone who has what is considered to be good values and whose behavior reflects those values is said to be a moral person and to be someone who acts morally.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 6

ETHICS → VALUES → MORALITY

Ethics then can be seen as values in action, and ethics are generated by the values of a group or a society or what that group or society believes is good or bad. Ethics is a set of rules for what society should and should not do and values are the underpinnings for specific ethics.

Morality refers to how closely an individual or a group adheres to a set of ethics. A simple example can be used to connect these concepts. It is illegal to physically harm another person except for the purpose of self-defense or protecting someone else.

Causing physical harm is illegal because we value each individual’s health and safety and believe that causing injury or pain to another person is wrong. Someone who commits a battery will be judged to have behaved immorally and perhaps unethically, as well. The specific value determines what is good or bad behavior.

Ethics, Law, Religion, And Conscience

Ethics are not law and laws are not ethics. Laws may be derived from ethics. Unlike ethics laws are binding and must be recognized by every member of a society. There can be ethical disputes, which remain simply disputes; but, breaking a law is quite different.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 7 Violation of a law is associated with a specific punishment; whereas, to violate an ethical standard may or may not be punishable. Importantly, ethics are not religion. Ethics are certainly part of religion, but religion is personal acceptance and belief in a system that has associated ethics, values, and morals. Ethics are not individual feelings of what is right or wrong. Ethics are not the conscience. Conscience belongs to an individual. Ethics are shared and social.

The Nursing Profession And Ethics

A concern with ethics has always been a part of the nursing profession. Florence Nightingale developed a pledge in the 1800s, and it is the basis for much of the current code of ethics. Nightingale’s pledge states:

I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all

family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 8 In 2001, the ANA developed a code of ethics and it is considered the gold standard for nursing ethical practice. This code has been modified over the years but the nine provisions of the code (which are described below) have remained essentially the same, as have its major themes of beneficence, remaining loyal to the profession, performing beneficial services, and maintaining honesty to yourself and the patients.

The nine provisions of the ANA code are described in an abbreviated form in Table 2. (A provision is defined as a condition or a requirement. The full text is available as a read-only document or for purchase on the ANA website at http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses.a spx).

The ANA ethical code outlines the values of the profession. These values are not limited to the nurse-patient relationship but the code describes what nurses should understand about their ethical responsibilities to patients, and to co-workers and others. It also informs others what is expected of nurses.

Nurses who follow the ANA code of ethics will provide quality care, promote the profession of nursing, and increase their degree of professionalism.

In Table 2, below, the reader is guided through each statement in the ANA code of ethics that addresses nursing practice, commitment to the patient, advocacy, duty to self and to others, and the nurses overall professional interactions with others and collective participation to promote the profession and wellbeing of patients.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 9 Table 2: American Nursing Association Code Of Ethics

1. The nurse practices with compassion and respect for the inherent dignity and worth of each person. 2. The nurse’s primary commitment is to the patient. 3. The nurse advocates for, protects, and promotes the health of patients. 4. The nurse has accountability, authority, and responsibility for nursing practice, and makes decisions and takes actions to provide care. 5. The nurse has the same duty to self as to others, promoting health, personal and professional development, safety and health. 6. By individual and collective action the nurse establishes, maintains, and improves the ethical environment of the work setting. 7. The nurse advances the profession through policy development, research and scholarly inquiry. 8. The nurse collaborates with other health professionals and the public to protect human rights, and to promote health diplomacy and reduce health disparities. 9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Practical Applications Of The Provisions Of The ANA Code Of Ethics

This section will re-examine several of the nine provisions of the ANA code of ethics and place each one in the context of a clinical concern, question, or situation. The following section will discuss possible answers or solutions to the examples that have been presented.

The provisions of the ethical code are clear and unambiguous. For example, the first provision states in part that the nurse practices with respect for the inherent dignity of the patient, and the third provision states that a nurse nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 10 should advocate for the health of patients. Concern for the dignity and health of others and working to maintain and preserve someone’s dignity and health are seen as good; these qualities and behaviors are valued.

Although the provisions of the ethical code are quite plain and not complicated, applying them and using them is not always straightforward. Consider the following points.  An ethical code is applied in situations in which all the data and facts may not immediately be available and/or in situations that are in flux. It is simple to say that nurses should protect a patient’s health but health and health needs are different for each person and are frequently changing.

 The terms of an ethical code may be defined and interpreted differently by each individual. For example, what do the terms “advance” and “promote” mean in a given situation? How can advance and promote be measured? And who decides what these terms mean in a specific circumstance? Should the patient’s or the healthcare professional’s definitions of health and healthcare be used?

 Cultures change, societies change, and the expectations patients have of healthcare systems and healthcare professionals change. An ethical code defines what is considered to be good or bad, and nurses hold to these values while caring for patients in environments that are constantly evolving.

At this point the theme should be clear: the provisions of the ANA code of ethics provide direction but not instructions. In addition, the nine provisions can be interpreted in different ways. Applying the provisions in practical,

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 11 day-to-day situations requires flexibility and professional judgment and using these provisions requires input from patients and collaboration with other healthcare professionals. Ethics do not and cannot provide solutions or answers for specific problems or situations. They can only serve as a guide for ethical and moral conduct.

Provision Number 1: The Nurse Practices with Compassion and Respect for the Inherent Dignity and Worth of Each Person

Compassion is awareness of the suffering of others and a desire to alleviate suffering. Respect is defined as recognition of the worth or value of someone or something. These are concepts we all understand and they are two of the primary values of the ANA code of ethics, but who defines suffering? What is acceptable in terms of alleviating suffering and what is excessive or intrusive? What is compassionate behavior?

The definitions and concepts are simple. Application of them is not and knowing what to do in any particular patient-nurse interaction or patient care situation can be challenging. Answers are not always simple or straightforward.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 12 Example #1: How can a nurse manage a situation in which he or she suspects a patient is requesting an opioid analgesic less for the purpose of pain relief than for euphoria?

Management of pain is a nursing responsibility and it certainly involves compassion and a desire to alleviate suffering. But patients’ expectations of how nurses should be involved in pain management can vary significantly. In simpler terms they expect nurses to care about their pain, but caring has a different meaning for each person.

Patients and caregivers may also have distinctly different ideas of what is an acceptable level of pain and what is reasonable in terms of pain relief. In addition, healthcare providers need to maintain some emotional distance in order to give competent care so balancing objectivity and compassion is difficult.

Dignity is considered to be the quality or state of being worthy of honor or respect. The ANA code stresses that dignity is intrinsic to all people, and it emphasizes that each person has an inherent worth. We all have value and inherent worth simply by being human and so each person should be treated with dignity. Everyone is deserving of this basic consideration, regardless of the situation or our feelings. The nurse should not be influenced by the person’s social status, health conditions, economic status, or personal attributes. Every patient and co-worker should be treated equally. Nurses may still dislike a patient or a colleague but expressing these feelings should not be done in any way that interferes with patient care.

People who are hospitalized are exposed to many threats to their dignity; i.e., lack of privacy, lack of modesty, and loss of autonomy and control. In

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 13 addition, there are many possible interpretations of honor, respect, and inherent worth, and these are all influenced by factors such as age, cultural or ethnic background, sexual orientation, and religious belief.

Example #2: Someone suffers a traumatic brain injury and it is determined that the patient has suffered brain death.

The spouse feels that the best way to honor the patient’s dignity and inherent worth is to stop all medical interventions and let the patient die. The patient’s siblings feel that allowing the patient to die is the ultimate measure of disrespect and would be equivalent to murder and many people would agree.

Provision Number 2: The Nurse’s Primary Commitment is to the Patient

This provision needs little explanation as the impetus and motivation for a career in nursing is caring for patients. But clearly identifying what the words “commitment to the patient” means in a given situation can be difficult.

Example #3: A patient’s family has voiced doubts to the nurse and to the patient about the efficacy of a particular therapy their relative is receiving; they feel that the treatment may be dangerous and they want it stopped.

The patient’s family has not told the prescribing physician about their feelings. The patient has not expressed any such concerns, but the nurse notices when interacting with the prescribing physician that the patient seems hesitant and unsure.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 14 The patient has the mental acuity to ask for and understand information, and is very close to his family. It is clear to the nurse and the other nursing team members that the physician’s recommendations are safe and in the patient’s best interest, and refusing this treatment would be harmful to the patient. The primary commitment of the nurse is to the patient but how is this best expressed in this situation?

Provision Number 3: The Nurse Advocates for, Protects, and Promotes the Health of Patients.

There are many ways that nurses may advocate for a patient’s health. They do so most often in situations in which the patient needs advice and counseling from a professional. Protecting a patient’s health means having a vigilant interest in patient welfare and safety and taking proactive steps to maintain them, and promoting a patient’s health involves actively encouraging and supporting anything that preserves and improves health. All of these values are focused on health, but each individual has a personal definition of health and that definition changes.

Example #4: The nurse is caring for a 73-year-old female who has congestive heart failure (CHF). Her disease has been well-controlled and her symptoms minimal through the use of a diuretic and an ACE inhibitor, but in the past several months she has been increasingly short of breath.

The patient’s physician advises the patient to lose weight, exercise, make some changes in diet, and prescribes a nitrate and an angiotensin-receptor blocker. This treatment plan is not unusual and will almost certainly be effective. But the patient is very reluctant to comply with the physician’s recommendations; she states that she “feels fine.”

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 15 Should the nurse encourage the patient to accept these changes and, if so, how vigorous should this encouragement be? What is the ethical solution for these patient care situations?

Example # 1: How can a nurse manage a situation in which she suspects a patient is requesting an opioid analgesic less for the purpose of pain relief than for euphoria?

Nurses are ethically bound to treat patients with compassion and respect. But nurses should also protect and promote patient health, and, for nurses to inappropriately administer controlled substances would not be promoting or protecting health. The great majority of patients who request a strong analgesic do so because they are having pain, but abuse of, and unhealthy dependence on opioids, are not uncommon. It is also possible that abuse, unhealthy dependence, and pain can co-exist.

This is a difficult scenario and the answer requires asking questions, knowledge, and collaboration. Is it likely the patient is having pain? Does she/he have a history of opioid abuse or dependence? Would it be clinically safe to administer an opioid analgesic at the time of the request? Are there alternatives that would provide analgesia and would be acceptable to the patient? And, if the patient is seeking euphoria and has an unhealthy dependence on opioids, would giving or denying the patient this dose be especially harmful or beneficial? Talking with the patient, speaking with the patient’s physician, consulting with other nurses, or seeking advice from a substance abuse counselor or addictions specialist can help to obtain answers to these questions.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 16 Example # 2: Someone suffers a traumatic brain injury and it is determined that the patient has suffered brain death.

The spouse feels that the best way to honor the patient’s dignity and inherent worth is to stop all medical interventions and let the patient die. The patient’s parents feel that allowing their daughter to die is the ultimate measure of disrespect and would be equivalent to murder and many people would agree.

This example illustrates an ethical issue that has gathered much attention and at times has involved the U.S. Supreme Court and a sitting president. In 1990, 27-year-old Teri Schiavo had a cardiac arrest. She was successfully resuscitated but suffered irreversible hypoxic brain damage. She was diagnosed as being in a permanent vegetative state with no hope for recovery. Her husband wanted all interventions stopped, including hydration and nutrition, claiming that Teri would not have wanted to continue to live in this condition. Teri’s parents vehemently disagreed. After 15 years and a protracted court battle Schiavo’s spouse prevailed and she was allowed to die.

There is no right or wrong answer to this situation, there are only conflicting values and the solution was found in the law. End-of-life issues are not black and white, but many shades of gray. It often comes down to working with the patient to determine how her/his care should proceed at the end of life. Even had Teri Schiavo been conscious and able to decide for herself that she did not want to live there are many people who feel that life should always be preserved.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 17 Ethically no nurse can act in a way with the sole intention of ending someone’s life. Many times nurses perform activities such as administering pain medication to a terminally ill patient that may speed up the dying process. But the right to choose what treatment to accept or refuse, even if that choice might result in what some people would consider an unnatural death, is one of the foundations of our healthcare system. Respecting a patient’s autonomy is a basis for the ANA code of ethics. In a situation similar to that of Teri Schiavo, the nurse who feels he/she cannot be a part of actions that would allow someone to die should not participate in that patient’s care. Influencing anyone who agrees or opposes would be unethical. Participating in the decision for or against removing life support would be unethical.

Example # 3: A patient’s family has voiced doubts to the nurse and to the patient about the efficacy of a particular therapy their relative is receiving. They feel that the treatment may be dangerous and they want it stopped.

The patient’s family has not told the prescribing medical provider about their feelings. The patient has not expressed any such concerns, but the nurse notices that when interacting with the prescribing physician there is notable hesitancy and the patient appears unsettled. The patient has the mental acuity to ask for and understand information, and he is very close to his family. It is clear to the nurse and the other nurses on the team that the physician’s recommendations are safe and in the patient’s best interest and that refusing this treatment would be harmful. The primary commitment of the nurse is to the patient, but how is this commitment best expressed in this situation?

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 18 It would be sensible and ethical for the nurse to discuss the situation with the patient and the family and to encourage them to have a group meeting with the physician. Additionally, the nurse should determine the level of knowledge of the family members and the patient, and to ask them if it would be acceptable for the nurse to notify the physician about what is happening. If the patient and family refuse, this places the nurse in a difficult situation. The nurse is committed to the patient’s health and welfare and to making sure that everyone involved in the patient’s care is well- informed, which could be viewed as commitment to the patient.

Yet, the nurse must also respect the patient’s autonomy. At that point the only ethical course of action is to be sure that the patient and the family have all the facts they need to make an informed decision and to ensure they understand the risks and benefits of accepting or rejecting this treatment. If the decision to refuse treatment would pose an imminent and serious threat to the patient’s safety, it would probably be ethical to inform the patient’s physician, regardless of their wishes. If this is not the case, the decision to do this would be much more difficult.

Example #4: The nurse is caring for a 73-year-old female who has congestive heart failure (CHF). Her disease has been well controlled and her symptoms minimal through the use of a diuretic and an ACE inhibitor, but in the past several months she has been increasingly short of breath.

The patient’s physician advises the patient to lose weight, exercise, make some changes in diet, and wants the patient to begin taking a nitrate and an angiotensin-receptor blocker. This treatment plan is not unusual and will certainly be effective yet the patient is very reluctant to comply with the physician’s recommendations. She states that she feels fine. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 19 The physician’s recommendations will improve the patient’s health. Provision number 3 of the ANA code of ethics states that the nurse advocates, protects, and promotes the health of patients. Patients are often reluctant to accept new therapies and make lifestyle changes, but the nurse has personally observed how the signs and symptoms of CHF can be improved and quality of life improved with the treatment’s the physician is prescribing. The nurse also knows that many people need time to adjust to a change in their medical regimens. Given these facts, the obvious conclusion would be that the nurse should strongly encourage the patient to comply.

However, provision number 1 requires nurses to respect the dignity of patients. Autonomy in matters of health is a part of dignity, and patients have the right to choose which treatments they want and to refuse treatments that they do not want. Also, health is more than vital signs and improvement of symptoms. In this situation the ethical course of action would involve conversation and education. The patient should be consulted to find out why she is reluctant to accept these changes. Her knowledge of what these therapies and lifestyle interventions entail, i.e., benefits, risks, and level of commitment, should be determined. It may be appropriate to consult with dieticians, a physical therapist, a pharmacist, and perhaps the patient’s family. In short, the nurse needs to know why the patient feels the way she does, and the nurse should make sure that the patient has everything she needs to make an informed decision.

Nurses need to understand their patients’ values and allow them to participate in goal setting. Practical steps for nurses to take to implement this provision include:  Having a care plan meeting to discuss goals of the patient.  Act as a patient advocate.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 20  Develop a strong collaborative relationship between nurse and medical provider. Nurses who have a strong relationship with attending providers have more influence on their ability to act as an advocate for patients. Developing a good collaborative relationship requires that the nurse is a good communicator and is trustworthy, knowledgeable and respectful.  Maintain patient confidentiality. Nurses have a responsibly to their patient to protect their privacy and safeguard information.  Be aware of conflicts of interest.

Other Provisions Of The ANA Code Of Ethics

Provision number 4 states that the nurse has accountability, authority, and responsibility for nursing practice. This provision stresses that nurses are independent professionals and responsible for their actions and decisions.

Provision number 5 states that the nurse has a duty to take care of her/himself. The nurse should maintain integrity, maintain professional growth, remain safe, and monitor his/her own competence. This provision asks the nurse to detect any problems from within and determine the best course of action to remedy them. The goal of this provision is to promote self-respect and professional growth.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 21 Nurses need to maintain a balance between life and work. It is an ethical responsibility to maintain personal competence and to recognize areas of personal knowledge and performance that need improvement. It is also the individual’s responsibility to keep up with advances in the field. Activities to improve professional competence include: taking continuing education courses, talking to more experienced employees, asking employers for more training, attending seminars, taking self-study courses, getting more certifications, being involved in research, and returning to school.

Provision number 6 requires the nurse to establish, maintain, and improve the ethical environment of the work setting. Caring for patients is the primary commitment of a nurse, but the best efforts of an individual to provide good care will not be successful if the workplace environment is sub- optimal. Establishing, maintaining, and improving the workplace environment must be done on an individual and a collective basis. Staff nurses should be encouraged to point out workplace issues that interfere with delivery of care. Nurses who work in administration have a primary role to assure that the healthcare environment provides good quality healthcare. If the organization cannot or will not improve the healthcare environment and care, the ethical course of action may require the nurse to seek other employment.

Provision number 7 addresses the need for individual responsibility for the profession. It recognizes that healthcare and healthcare needs are not static and nurses should attempt to advance the profession by contributions to education, research, and policy development.

Provision number 8 identifies one of the essential components of nursing care, collaboration. Nurses do not and cannot operate in isolation and they

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 22 cannot take care of every healthcare need. In addition, finding ethical solutions to patient care issues often requires consultation with other healthcare professionals.

Provision number 9 is closely associated with provision number 4, which states that the nurse has accountability, authority, and responsibility for nursing practice. Provision number 9 states that nurses have a role in making sure that nursing values are articulated and that the integrity of the profession is maintained. Nurses are independent professionals and provision number 9 of the ANA code of ethics recognizes that maintaining this independence requires the nursing profession to ensure its standards and ethics are upheld. The nursing profession must also actively promote these values.

The Process Of Making Ethical Decisions

Using nursing ethics and acting ethically in day-to-day practice can be complicated. There is no substitute for experience, but the learning curve of making proper ethical decisions can be shortened and made easier by considering it as a process. The steps listed below are an example: this process can be modified as needed.

Ethical Decision Making

Step 1: Is this an ethical issue? Ethics are specific behaviors and attitudes that a group of people or a society considers to be beneficial or harmful. The primary ethics of nursing could be considered commitment to the patient and taking action to benefit his/her health, but those ethics can be broadly defined. Make sure the issue is one that involves the provisions of the nursing code of ethics. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 23 Step 2: Define the issue. This step of any problem solving process is often overlooked but it is vital.

Step 3: Gather information. If needed consult with other nurses or healthcare professionals. Ethical decisions often require collaboration.

Step 4: Review previous ethical issues that are similar. What worked, what didn’t, and why?

Step 5: Make a plan. A useful adjunct to this step is explanation. Imagine explaining a plan of action to someone. Would it be defined and clear? Would other nurses consider the stated reasons for the plan ethical? Is the plan practical and are there well-defined ways in which its success or failure can be measured? Are the steps of the plan and the outcomes measurable? If the answer is ‘no’ to any of these questions, then the plan should be reformulated.

Step 6: Evaluate the success of the plan.

Using the Process of Ethical Decision Making

In example #3, described above, a patient’s family has voiced doubts to the nurse and to the patient about the efficacy of a particular therapy the patient is receiving; the family feels that the treatment may be dangerous and want it stopped. They have not told the prescribing physician about their feelings. The patient has not expressed any such concerns, but the nurse notices that when interacting with the prescribing physician that the patient seems hesitant and unsure. The patient has the mental acuity to ask for and understand information, and he is very close to his family. It is clear to the nurse and to the other nurses of the team that the physician’s nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 24 recommendations are safe and in the patient’s best interest and that refusing this treatment would be harmful. If the decision to refuse treatment would pose an imminent and serious threat to the patient’s safety, it would be ethical to inform the patient’s physician. If this is not the case, the decision to do this would be much more difficult.

The primary commitment of the nurse is to the patient but how is this commitment best expressed in this situation?

Step 1: Is this an ethical issue? Yes; the primary commitment of the nurse is to the patient and the nurse should promote and protect a patient’s health.

Step 2: Define the issue. The issues here are patient safety, patient dignity, and patient autonomy.

Step 3: Gather information. The nurse should speak to the patient and to the family members. This can be done circumspectly and in a way that is non-intrusive. Other nurses should be consulted as well.

Step 4: Review previous ethical issues that are similar.

Step 5: Make a plan. A sensible plan for (hopefully) solving this ethical issue would have four components: 1) finding out why the family feels as they do; 2) finding out what the patient feels; 3) determine what the patient and the family knows; and, 4) provide them with the information they need to make an informed decision. These should be the goals of the plan.

The nurse should decide what she/he will say and how to say it before meeting with the family members and the patient. Knowing the facts about

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 25 the risks and benefits of the therapy is critical. The nurse should be clear to the family and patient about any concerns and to reassure them that she/he is not trying to interfere with their relationship with the medical provider. If the decision to refuse treatment would pose an imminent and serious threat to the patient’s safety, it would be ethical to inform the patient’s provider regardless of their wishes. If this is not the case, the decision to do this would be much more difficult. Either way, the nurse must be sure that the patient and his/her family understand the implications of refusing this treatment.

Step 6: Evaluate the success of the plan. The plan can be evaluated by: 1) getting feedback from the patient and the family that confirms the nurse’s understanding of their feelings; and, 2) confirming that the patient and family understand the information the nurse has provided.

Summary

The American Nurses Association code of ethics outlines the ethics of the nursing profession and reflects its values. The code provides an ethical framework, but applying the provisions of the code requires experience, flexibility, and judgment. Situations that demand ethical decision-making are common in the nursing profession. Using a standardized decision making process in these situations can provide a better and more efficient outcome.

Steps nurses can take to improve ethical behavior include respecting the human dignity of all people, and the privacy and confidentially of all patients. Nurses need to be aware of situations that promote unethical behavior. This may include a poor work environment, as overworked nurses are more likely to compromise ethics to reduce personal stress. Nurses are required to

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 26 assume responsibility and accountability for all their actions. This includes participation in continuing education to promote nursing competence.

Participation in research and other activities that promote nursing, as well as in activities that enhance a good work environment are fundamental to professionalism and to safe patient outcomes. This involves the nursing role to develop professional relationships, demonstrate collegiality and promote nursing growth through mentoring and supporting colleagues.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 27 1) Ethics are defined as behaviors/attitudes that a group considers desirable or harmful. personal feelings about right and wrong. beliefs that categorize attitudes and behaviors as good or bad. a system of morality.

2) Values are defined as personal feelings about right and wrong. beliefs that categorize attitudes and behaviors and good or bad. legally enforced morals. behaviors/attitudes that group considers desirable or harmful.

3) Which of the following is a specific provision of the ANA code of ethics? Nurses should not profit unreasonably from their work. The nurse’s primary commitment is to the patient. A nurse should collaborate with other healthcare professionals. Nurses not interfere with a patient’s decision to refuse treatments.

4) Which of these could be considered a provision of the ANA code of ethics? A nurse is responsible only for the care that she/he provides. Each nurse must provide competent and timely care. A nurse should sympathize with his/her patients. Nurses should practice with compassion and respect.

5) The ANA code of ethics is considered equivalent to laws. True. False.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 28 6) According the ANA code of ethics nurses should advocate for, protect, and promote patient health. obtain advanced degrees, if possible. never act independently; they are part of a team. treat patients in a way that ignores age, gender, and sexual orientation.

7) The ANA code of ethics states that nurses have responsibility for nursing practice. This provision is used to assign legal responsibility for nursing actions. This provision is intended to differentiate nurses from physicians. This provision reinforces that nurses are independent professionals. This provision clearly outlines what nurses can and cannot do.

8) Ethics in nursing are limited to the actions of the individual nurse. True. False.

9) Ethical decisions frequently require collaboration with other healthcare professionals. are seldom complicated or difficult. seldom require collaboration with other healthcare professionals. should never involve the patient; the nurse is the professional.

10) According to the ANA code of ethics the nurse’s primary commitment is to providing safe and accurate care. is to act morally and with compassion. is to the patient. is to honesty and compassion in practice.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 29 11) ______is awareness of the suffering of others and a desire to alleviate suffering. Sympathy Compassion Respect Empathy

12) ______is defined as recognition of the worth or value of someone or something. Respect Compassion Autonomy Empathy

13) Provision number 3 of the ANA code of ethics states that the nurse advocates, protects, and promotes the health of patients nurtures, educates, and advocates for patients provides care, acts collaboratively and delivers safe care to patients None of the above.

14) Ethically a nurse can act in a way with the sole intention of ending someone’s life if the patient has a terminal illness and a living will to be allowed to die. True False

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 30 15) Provision number 4 of the ANA states that the nurse has legal and moral duty to provide ethical nursing accountability, authority, and responsibility for nursing practice professional knowledge and experience to deliver ethical care a moral obligation to provide safe and affordable care

16) ______developed a pledge in the 1800s, and it is the basis for much of the current code of ethics Hildegard Peplau Betty Neuman Florence Nightingale Faye Abdellah

17) A well-known case that went before the U.S. Supreme Court in 1990 involved the right to end the life of 27-year-old ______. Teri Schiavo Christie White Alan Young None of the above

18) Developing a good collaborative relationship requires that the nurse is a good communicator trustworthy/respectful knowledgeable all of the above

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 31 19) Violation of a law is associated with a specific punishment; whereas, to violate an ethical standard may or may not be punishable. True False

20) The ANA code stresses that ______(the quality or state of being worthy of honor or respect) is intrinsic to all people, and that each person has an inherent worth. self-worth dignity autonomy independence

Correct Answer Key: 1. Ethics are defined as Correct Answer: behaviors/attitudes that a group considers desirable or harmful.

2. Values are defined as Correct Answer: beliefs that categorize attitudes and behaviors and good or bad.

3. Which of the following is a specific provision of the ANA code of ethics? Correct Answer: The nurse’s primary commitment is to the patient.

4. Which of these could be considered a provision of the ANA code of ethics? Correct Answer: Nurses should practice with compassion and respect.

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 32 5. True or false: The ANA code of ethics is considered equivalent to laws. Correct Answer: False.

6. According the ANA code of ethics nurses should Correct Answer: advocate for, protect, and promote patient health.

7. The ANA code of ethics states that nurses have responsibility for nursing practice. Correct Answer: This provision reinforces that nurses are independent professionals.

8. True or false: Ethics in nursing are limited to the actions of the individual nurse. Correct Answer: False.

9. Ethical decisions Correct Answer: frequently require collaboration with other healthcare professionals.

10. According to the ANA code of ethics the nurse’s primary commitment Correct Answer: is to the patient.

11. ______is awareness of the suffering of others and a desire to alleviate suffering. Correct Answer: Compassion

12. ______is defined as recognition of the worth or value of someone or something. Correct Answer: Respect

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 33 13. Provision number 3 of the ANA code of ethics states that the nurse Correct Answer: advocates, protects, and promotes the health of patients

14. True/False. Ethically a nurse can act in a way with the sole intention of ending someone’s life if the patient has a terminal illness and a living will to be allowed to die. Correct Answer: False

15. Provision number 4 of the ANA states that the nurse has Correct Answer: accountability, authority, and responsibility for nursing practice

16. ______developed a pledge in the 1800s, and it is the basis for much of the current code of ethics. Correct Answer: Florence Nightingale

17. A well-known case that went before the U.S. Supreme Court in 1990 involved the right to end the life of 27-year-old ______. Correct Answer: Teri Schiavo

18. Developing a good collaborative relationship requires that the nurse is a Correct Answer: All of the above

19. True/False. Violation of a law is associated with a specific punishment; whereas, to violate an ethical standard may or may not be punishable. Correct Answer: True

nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 34 20. The ANA code stresses that ______(the quality or state of being worthy of honor or respect) is intrinsic to all people, and that each person has an inherent worth. Correct Answer: dignity

References Section

The reference section of in-text citations include published works intended as helpful material for further reading. Unpublished works and personal communications are not included in this section, although may appear within the study text.

1. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. 2001. Retrieved December 9, 2009. Available from URL: http://nursingworld.org/ethics/code/protected_nwcoe303.htm 2. Nightingale F. Nightingale Pledge. Code of ethics. Retrieved from: URL: http://www.texashste.com/documents/curriculum/code_of_ethics.pdf

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