NURSING ETHICS

Nursing ethics involves rules and principles to guide right conduct in terms of moral duties and obligations to protect the rights of human beings. In nursing, ethical codes provide professional standards and formal guidelines for nursing activities to protect both the nurse and the patient.

1. Code of ethics - serves as a frame of reference when judging priorities or possible courses of action. Purposes:
1. To provide a basis for regulating relationships between nurse, patient, co-workers, society, and profession.
2. To provide a standard for excluding unscrupulous nursing practitioners and for defending nurses unjustly accused.
3. To serve as a basis for nursing curricula.
4. To orient new nurses and the public to ethical professional conduct.


2. ANA Code of Ethics for Nurses incorporates the following key elements of what the nurse needs to do*:
1. Demonstrate respect for human dignity and uniqueness of individual regardless of health problem or socioeconomic level
2. Maintain patient’s right to privacy and confidentiality
3. Protect the patient from incompetent, unethical, or illegal behavior of others
4. Accept responsibility for informed individual nursing judgment and behavior
5. Maintain competence through ongoing professional development and consultation
6. Maintain responsibility when delegating nursing care, based on competence/qualification criteria
7. Work on maintaining/improving standards of care in employment setting
8. Protect consumer from misinformation/ misrepresentation


3. Bioethics - a philosophical field that applies ethical reasoning process for achieving clear and convincing reasons to issues and dilemmas (conflicts between two obligations) in health care.
1. Purpose of applying ethical reflection to nursing concerns:
1. Improve quality of professional nursing decisions.
2. Increase sensitivity to others.
3. Offer a sense of moral clarity and enlightenment.
2. Framework for analyzing an ethical issue:
1. Who are the relevant participants in the situation?
2. What is the required action?
3. What are the probable and possible benefits and consequences of the action?
4. What is the range of alternative actions or choices?
5. What is the intent or purpose of the action?
6. What is the context of the action?
3. Principles of bioethics:
1. Autonomy - the right to make one’s own decisions.
2. Nonmalfeasance - the intention to do no wrong.
3. Beneficence - the principle of attempting to do things that benefit others.
4. Justice - the distribution, as fairly as possible, of benefits, resources, and burdens.
5. Veracity - the intention to tell the truth.
6. Confidentiality - the social contract guaranteeing another’s privacy.


4. Patient bill of rights
1. Right to appropriate treatment that is most supportive and least restrictive to personal freedom.
2. Right to individualized treatment plan, subject to review and reassessment.
3. Right to active participation in treatment, with the risk, side effects, and benefits of all medication and treatment (and alternatives) to be discussed.
4. Right to give and withhold consent (exceptions: emergencies and when under conservatorship).
1. Advance directives: legal, written, or oral statements made by a mentally competent person about treatment preferences. In the event the person is unable to make these determinations, a designated surrogate decision-maker can do so. Each state has own specific laws with restrictions.
1. Living will: legal document stating person does not wish to have extraordinary lifesaving measures when not able to make decisions about own care.
2. Durable power of attorney: legal document giving designated person authority to make health-care decisions on client’s behalf when client is unable to do so.
5. Right to be free of experimentation unless following recommendations of the National Commission on Protection of Human Subjects (with informed, voluntary, written consent.)
6. Right to be free of restraints and seclusion except in an emergency.
7. Right to humane environment with reasonable protection from harm and appropriate privacy.
8. Right to confidentiality of medical records.
9. Right of access to personal treatment record.
10. Right to as much freedom as possible to exercise constitutional rights of association (e.g., use of telephone, personal mail, having visitors) and expression.
11. Right to information about these rights in both written and oral form, presented in an understandable manner at outset and periodically thereafter.
12. Right to assert grievances through a grievance mechanism that includes the power to go to court.
13. Right to obtain advocacy assistance.
1. Definition: an advocate is a person who pleads for a cause or who acts on a client’s behalf.
2. Goals: help client gain greater selfdetermination and encourage freedom of choices; increase sensitivity and responsiveness of the health-care, social, political systems to the needs of the client.
3. Characteristics: assertiveness; willingness to speak out for or in support of client; ability to negotiate and obtain resources for positive outcomes; willingness to take risks, and take necessary measures in instances of incompetent, unethical, or illegal practice by others that may jeopardize client’s rights.
14. Right to criticize or complain about conditions or services without fear of retaliatory punishment or other reprisals.
15. Right to referral to complement the discharge plan.


5. Conflicts and problems - Ethical dilemmas
1. Personal values versus professional duty - nurses have the right to refuse to participate in those areas of nursing practice that are against their personal values, as long as a patient’s welfare is not jeopardized. Example: therapeutic abortions.
2. Nurse versus agency - conflict may arise regarding whether or not to give out needed information to a patient or to follow agency policy, which does not allow it. Example: an emotionally upset teenager asks a nurse about how to get an abortion, a discussion that is against agency policy.
3. Nurse versus colleagues - conflict may arise when determining whether to ignore or report others’ behavior. Examples: you see another nurse steal medications; you know that a peer is giving a false reason when requesting time off; or you observe an intoxicated colleague.
4. Nurse versus patient/family - conflict may stem from knowledge of confidential information. Should you tell? Example: patient or family member relates a vital secret to the nurse.
5. Conflicting responsibilities - to whom is the nurse primarily responsible when needs of the agency and the patient differ? Example: an MD asks a nurse not to list all supplies used for patient care, because the patient cannot afford to pay the bill.
6. Ethical dilemmas - stigma of diagnostic label (e.g., AIDS, schizophrenic, addict); involuntary psychiatric confinement; right to control individual freedom; right to suicide; right to privacy and confidentiality.


6. Trends in nursing practice
1. Overall characteristics
1. Some trends are subtle and slow to emerge; others are obvious and quickly emerge.
2. Trends may conflict; some will prevail, others get modified by social forces.
2. General trends
1. Broadened focus of care - from care of ill to care of sick and healthy, from care of individual to care of family. Focus on prevention of illness, promotion of optimum level of health, holism.
2. Increasing scientific base - in bio-socialphysical sciences, not mere reliance on intuition, experience, and observation.
3. Increasingly complex technical skills and use of technologically advanced equipment, such as monitors and computers.
4. Increased independence in use of judgment, such as teaching nutrition in pregnancy and providing primary prenatal care.
5. New roles, such as nurse-clinician, require advanced skills in a particular area of practice. Examples: psychiatric nurse consults with staff about problems; primary care nurse takes medical histories and does physical assessment; one nurse coordinates 24-hour care during hospital stay; independent nurse practitioner has her or his own office in community where patients come for care; case management.
6. Community nursing services rather than hospital based; needs of the healthy are served as well as those of the ill.
7. Development of nursing standards to reflect specific nursing functions and activities.
1. Ensure safe standard of care to patients and families.
2. Provide criteria to measure excellence and effectiveness of care.
3. Trends in care of childbearing family
1. Consumerism:
1. Consumer push for humanization and individualization of health care during the childbearing cycle to reflect patient’s role in decision making, preferences, and cultural diversity.
2. Emphasis on family-centered care (including father, siblings, grandparents).
3. Increase in options available for conduct of birth experience and setting for birth: birthing homes, alternative birth center (ABC) in hospitals; birthing chairs; side-lying position for birth; family-centered cesarean birth; health-care provider (MD, RN, lay midwife); length of postpartum stay.
4. Increased consumer awareness of legal issues, patient’s rights.
5. Major nursing role: patient advocate.
2. Social trends:
1. Alternative lifestyles of families - single parenthood, communal living, surrogate motherhood, marriages without children.
2. Earlier sexual experimentation - availability of assistance to emancipated minors.
3. Increase in number of older (>38 yr) primíparas.
4. Legalization of abortion; availability to emancipated minors.
5. Smaller families.
6. Rising divorce rates.
3. Technologies:
1. Development of genetic and bioengineering techniques.
2. Development of prenatal diagnostic techniques, with options for management of each pregnancy.
3. In vitro fertilization and embryo transplantation.
4. Trends in community mental health (1960s - 1990s)
1. Shift from institutional to community-based care.
2. Preventive services.
3. Consumer participation in planning and delivery of services.
4. Original 12 essential services (1975) reduced to 5 (1981).
1. 24-hour inpatient care.
2. Outpatient care.
3. Partial hospitalization (day or night).
4. Emergency care.
5. Consultation and education.
6. Follow-up care.
7. Transitional services.
8. Services for children and adolescents.
9. Services for elderly.
10. Screening services (courts).
11. Alcohol abuse services.
12. Drug abuse services.
5. Protecting human rights of persons in need of mental health care.
6. Developing an advocacy program for chronically mentally ill.
7. Improving delivery of services to underserved and high-risk populations (e.g., minorities).
5. ANA Standards of Clinical Nursing Practice
1. Use of nursing process: assessment, nursing diagnosis, planning, implementation, evaluation, outcome identification.
2. Performance appraisal review.
3. Continuing education.
4. Collegiality; peer review.
5. Ethics.
6. Interdisciplinary collaboration.
7. Research.
8. Resource utilization - utilization of community health systems.
6. Four levels of nursing practice
1. Promotion of health to increase level of wellness. Example: provide dietary information to reduce risks of coronary artery diseases.
2. Prevention of illness or injury. Example: immunizations.
3. Restoration of health. Example: teach how to change dressing, care for wound.
4. Consolation of dying - assist person to attain peaceful death.
7. Five components of nursing care
1. Nursing care activities - assist with basic needs, give medications and treatments; observe response and adaptation to illness and treatments; teach self-care; guide rehabilitation activities for daily living.
2. Case management - a process that includes coordination of total patient care - all health team members should work together toward common goals.
3. Continuity of care - process of ensuring that ongoing physical, medical, and emotional health-care needs are assessed, planned for, and coordinated with all providers, for desired outcomes, without interruption of service when the location of care is transferred.
4. Evaluation of care - flexibility and responsiveness to changing needs: patients’ reactions and perceptions of their needs.
5. Delegate responsibility and direct nursing care provided by others - based on particular patient/family needs and on job description, roles, functions, and skills of other nursing personnel: client’s condition (stable or medically fragile), complexity of required care, potential risks for harm to client, degree of needed problem-solving expertise, predictability of outcome, type and level of client interaction required. Important: The person who delegated the task has the responsibility and final accountability for effective completion of task.
8. Three main nursing roles in relation to care of patients and their families (emphasis of each role varies with the situation, with adaptation of skills and modes of care as necessary)
1. Therapeutic role. Function: work toward “cure” in acute setting.
2. Caring role. Function: provide support through human relations, show concern, demonstrate acceptance of differences.
3. Socializing role. Function: offer distractions and respite from focus on illness.